Survival Benefit of Locoregional Treatment for Hepatocellular Carcinoma with Advanced Liver Cirrhosis

Abstract

Background & aims: Hepatocellular carcinoma (HCC) with decompensated liver cirrhosis (LC) is a life-threatening condition, which is amenable to liver transplantation (LT) as the standard first-line treatment. However, the application of LT can be limited due to a shortage of donor livers. This study aimed to clarify the effect of non-surgical therapy on the survival of patients with HCC and decompensated LC.

Methods: Of the 58,886 patients with HCC registered in the nationwide survey of the Liver Cancer Study Group of Japan (January 2000-December 2005), we included 1,344 patients with primary HCC and Child-Pugh (C-P) grade C for analysis in this retrospective study. Among the patients analyzed, 108 underwent LT, 273 were treated by local ablation therapy (LAT), 370 were treated by transarterial chemoembolization (TACE), and 593 received best supportive care (BSC). The effect of LT, LAT, and TACE on overall survival (OS) was analyzed using multivariate and propensity score analyses.

Results: Patient characteristics did not differ significantly between each treatment group and the BSC group, after propensity score matching. LAT (hazard ratio [HR]) =0.568; 95% confidence interval [CI], 0.40-0.80) and TACE (HR=0.691; 95% CI, 0.50-0.96) were identified as significant contributors to OS if the C-P score was less than 11 and tumor conditions met the Milan criteria.

Conclusions: For patients with HCC within the Milan criteria and with a C-P score of 10 or 11, locoregional treatment can be used as a salvage treatment if LT is not feasible.

Keywords: Best supportive care; Child-Pugh grade C; Local ablation therapy; Transarterial chemoembolization.

Fig. 1

a A comparison of OS among the BSC, LT, LAT, and TACE groups with C-P grade C. Patients who underwent LT, LAT, and TACE had significantly longer OS than patients who received BSC (p<0.0001). Moreover, there was significant difference in OS between the LT and LAT groups (p=0.0271) as well as the LT and TACE groups (p<0.0001). b A comparison of OS among the BSC, LT, LAT, and TACE groups with C-P grade C within the Milan criteria. The patients who underwent LT, LAT, and TACE had significantly longer OS than patients who received BSC (p<0.0001). The significant difference of OS was observed between the LT and LAT groups (p=0.0079) as well as the LT and TACE groups (p=0.0010).

Fig. 2

a A comparison of OS among the BSC, LAT, and TACE groups with C-P scores of 10 or 11. Each Kaplan-Meier survival curve represents the OS of patients who underwent LAT, TACE, and BSC. The patients who underwent LAT or TACE had significantly longer OS than patients who received BSC (p<0.0001). b A comparison of OS among the BSC, LAT, and TACE groups with C-P scores of 12-15. The Kaplan-Meier survival curves indicate that patients who underwent LAT or TACE had significantly longer OS than patients who received BSC (p<0.0001).

Fig. 3

a A comparison of OS between the BSC and LAT groups with C-P scores of 10 or 11, after matching patient backgrounds using propensity score analysis. The Kaplan-Meier curve shows that the LAT group had a lower risk of death than the BSC group (HR 0.568; 95% CI, 0.40-0.80; p=0.0014). b A comparison of OS between the BSC and TACE groups with C-P scores of 10 or 11, after matching patient backgrounds using propensity score analysis. The TACE group had a lower risk of death than the BSC group (HR 0.691; 95% CI, 0.50-0.96; p=0.0289). c A comparison of OS between the BSC and LAT groups with C-P scores of 12-15, after matching patient backgrounds using propensity score analysis. The LAT group had a lower risk of death than the BSC group (HR 0.601; 95% CI, 0.27-1.36; p=0.201). d A comparison of OS between the BSC and TACE groups with C-P scores of 12-15, after matching patient backgrounds using propensity score analysis. The TACE group had a lower risk of death than the BSC group (HR 0.626; 95% CI, 0.38-1.03; p=0.0549).