Defining Optimal Treatment for Outside Milan Criteria Hepatocellular Carcinoma - A Propensity Score Matched Analysis

Abstract

Objective: To compare the treatment efficacy of livertransplantation (LT) and liver resection (LR) for hepatocellular carcinomaoutside Milan Criteria (HCC/MC+) Background: Milan Criteria has been the gold standard forpatient selection in LT, despite high recurrence rate, LR is the only hope ofcure for patients with HCC/MC+. Recent reports demonstrated comparable survivalbetween HCC/MC+ and HCC/MC- after LT. However, study comparing the LT and LRfor HCC/MC+ in the context of propensity score (PS) matched analysis is scarce. Method: Patients with pathologically confirmed HCC/MC+were recruited from 1990 to 2016. HCC with evidence of major vascular orperitoneal invasion were excluded. PS matching was performed using hepatitis Bstatus, preoperative alpha-fetal protein (AFP) level, tumor size, tumor numberand MELD score. Patients from LT and LR group were matched in 1:2 ratio foranalysis. Results: There were 847 patients diagnosed withHCC/MC+. After PS matching, 138 patients, 46 from LT and 92 from LR group wereanalyzed. The median MELD and pre-transplant AFP was 9.35 and 41.5ng/mlrespectively. The median tumor number and size were 2 and 5cm respectively. Thefollow-up time was 63 months. There was no significant difference incomplication rate, hospital mortality and hospital stay between the groups. The5-year disease free survival for LT and LR group was 72.3% and 23.3% (P< 0.001)while the 5-year overall survival for LT and LR group was respectively 70% and41.3% (P= 0.004). Tumor number of 5 or above was found to be the only independentfactor affecting overall survival of HCC/MC+ patients in both LT and LR group (P=0.007,OR 1.98, 95%CI 1.21-3.24). Conclusion: LT is a superior surgical treatment whencompared to LR for patients with HCC/MC+. Tumor nodules 5 or above is associated with 3 times worse in overallsurvival after LT.