Analysis of the survival of patients with hepatocellular carcinoma and indications for liver transplantation or hepatic resection

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BACKGROUND: Hepatic resection (HR) and liver transplantation (LT) are potentially curative treatments for Hepatocellular carcinoma (HCC). The aim of this study was to analyze the survival of patients with HCC and indications for surgical treatment (HR or LT) in a high-volume center. METHODS: This was a retrospective cohort study of consecutive patients with HCC and indications for LT or HR from May 2006 to July 2019. Analysis of overall survival (OS) and disease-free survival (DFS) rates, univariate analysis and construction of a multivariable model to identify risk factors were performed. RESULTS: A total of 744 patients with HCC were evaluated, 563 (75.6%) of whom were enrolled in waiting list for LT and 181 (24.4%) of whom underwent HR. Among the patients enrolled in the waiting list, 362 (64.3%) underwent LT, whereas 201 (35.7%) remained on the waiting list (WL). From the group of 201 patients on the waiting list, 97 (48.2%) were removed from the list due to tumor progression beyond the Milan criteria (MC), and 83 (41.3%) died while waiting for the transplant. In the WL group, 97 (48.2%) patients were removed from the list due to tumor progression beyond the MC, another 83 (41.3%) patients died while waiting for the LT. The OS rates of the LT group were 77.4%, 67.5% and 56.8%, whereas those of the WL + LT (intention-to-treat) group were 59.9%, 47.3%, and 39.9%, and the HRs were 82.8%, 49.3%, and 33.4% at 1, 5 and 10 years, respectively (p = 0.001). Donor age (p = 0.002) and cold ischemia time (p < 0.001) were independent factors related to OS in the LT group, whereas the presence of significant portal hypertension (p < 0.001), alpha-fetoprotein (AFP) value (p < 0.001) and MC (p = 0.002) were independent factors for HR. The DFS rates for HR were 74.9%, 40.0% and 31.0%, and those for LT were 97.9%, 92.0% and 90.9% at 1, 5 and 10 years, respectively (p < 0.001). Higher AFP levels were identified as an independent factor for lower DFS in both groups. CONCLUSIONS: The present study revealed that the OS of patients listed for LT was greater in the first year than in the second year and that the results were similar to those of the HR in an intention-to-treat analysis. However, patients who achieve LT have better long-term outcomes, especially disease-free survival.

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