Digestive Diseases and Sciences, Vol. 34, No. 10 (October 1989), pp. 1571-1575 Reappraisal of Surgical Treatment of Small Hepatocellular Carcinomas in Cirrhosis: Clinicopathological Study of Resection or Transplantation LINO BELLI, MD, FEDERICO ROMANI, MD, LUCA S. BELLI, MD, LUCIANO DE CARLIS, MD, GIANFRANCO RONDINARA, MD, FABIO BATICCI, MD, ERNESTO DEL FAVERO, MD, ERNESTO MINOLA, MD, FRANCESCA DONATO, MD, VINCENZO MAZZAFERRO, MD, LEWIS TEPERMAN, MD, LEONARD MAKOWKA, MD, PHD, and DAVID H. VAN THIEL, MD Thirty-two patients with hepatocellular carcinoma (HCC) occurring in individuals with cirrhosis had a potentially curative surgical procedure. Twenty-two had segmental hepatic resections (HR), and 10 underwent orthotopic liver transplantation (OLTx). The diagnosis of hepatic malignancy was established in each case preoperatively, and each case was studied intraoperatively by means of sonography. Postoperatively each surgical specimen was examined pathologically with attention to the possibility of intrahepatic tumor spread. Twenty-three of the 32 patients had single small HCC lesion (<5 cm diameter) identified preoperatively. Sixteen of these underwent HR and seven underwent OLTx. Multiple additional neoplastic lesions were found in 19% of the 16 HR cases and in 14% of those undergoing OLTx when the resection specimens were examined pathologically. Vascular invasion was present in 43% of the OLTx patients and in 25% of the HR patients. Subtotal hepatic resection for small HCC occurring in cirrhosis has produced few long-term survivals. Both pre- and intraoperative sonography have been shown to underestimate the extent and distribution of these tumors. Based upon this experience that (I) vascular spread occurs often in HCC and (2) a high risk of postoperative hepatic failure can be expected after HR in cirrhotic individuals, OLTx is the most rational surgical procedure for such cases as it has the potential to cure. KEY WORDS: hepatocellular carcinoma; liver transplantation; liver surgery; liver tumor pathology. Recent advances in diagnostic radiology (both ultra- sound and CT scanning) and the serologic screening of cirrhotic patients for increased levels of alpha- fetoprotein have been responsible for the discovery Manuscript received January 3, 1989; revised manuscript received May 30, 1989; accepted June 9, 1989. From the Department of Surgery "Pizzamiglio II"; the Insti- tute of Pathology, Niguarda Hospital, Milan, Italy; Institute of Medicine (Clinica Medica III), University of Milan; and Depart- ments of Surgery and Gastroenterology, University of Pitts- burgh, Pittsburgh, Pennsylvania. Address for reprint requests: Dr. Federico Romani, Depart- ment of Surgery "Pizzamiglio II," Niguarda Hospital, Pza Ospedale Maggiore, 20162 Milan, Italy. of an increased number of hepatocellular carcino- mas (HCC) in cirrhotic individuals at an early stage of tumor development. These tumors are often asymptomatic and usually less than 5 cm in diame- ter (1-5). Such lesions, when small (less than 5 cm in diameter), have been amenable to partial hepatic resection with a reasonable expectation for patient survival for more than a year in several recent Japanese series (6-9). However, this success with hepatic resections of small hepatic tumors in cir- rhotic individuals seen in the West has yet to be confirmed (10). Digestive Diseases and Sciences, Vol. 34, No. 10 (October 1989) 0163-2116/89/1000-1571506.00/0 9 1989 Plenum Publishing Corporation 1571