Liver transplantation versus surgical resection for HCC meeting the Milan criteria: A propensity score analysis

Abstract

The optimal treatment (liver transplantation [LT] vs surgical resection [SR]) for early-stage hepatocellular carcinoma (HCC) remains controversial.A total of 209 SR patients and 129 LT patients were identified at our institution. After eliminating 27 patients with Child-Pugh C, the data from 209 SR patients and 102 LT patients were analyzed using a propensity score matching (PSM) model. Forty-six pairs were generated. A subgroup analysis was conducted based on the alpha-fetoprotein (AFP) level or platelet count (PLT). A survival analysis was performed using the Kaplan-Meier method.Gender, satellite lesions, and the treatment method were predictors of HCC recurrence. The Ishak score and treatment methods were associated with long-term survival after surgery. Before PSM, LT patients had a better prognosis than those treated by SR. Among HCC patients with childhood A/B cirrhosis, after PSM, SR achieved similar overall survival outcomes compared with LT. LT and SR resulted in comparable long-term survival for patients with or without thrombocytopenia. Patients with an AFP ≥ 400 ng/mL might achieve more survival benefits from LT.Our propensity score model provided evidence that, compared with transplantation, surgical resection could result in comparable long-term survival for resectable early-stage HCC patients, except for the AFP ≥ 400 ng/mL HCC subgroup. Surgical resection might not be a contraindication for early-stage HCC patients with thrombocytopenia due to their similar prognosis after transplantation.

Figure 1

Survival analysis before propensity score matching. The disease-free survival (DFS) (A) and overall survival (OS) rates (B) were higher in the liver transplantation (LT) group than in the surgical resection (SR) group. Child–Pugh classification had no impact on the DFS (C) and OS (D) in the LT group. DFS = disease-free survival, LT = liver transplantation, OS = overall survival, SR = surgical resection.

Figure 2

Covariate balance was improved in the matched samples. (A) Parallel line plot of the standardized difference in means before and after PSM in HCC patients within the Milan criteria. (B) Even distribution of propensity scores in the matched groups. HCC = hepatocellular carcinoma, PSM = propensity score matching.

Figure 3

Survival analysis after propensity score matching. (A) The liver transplantation (LT) group had a higher rate of disease free survival (DFS). (B) The surgical resection (SR) group achieved a comparable overall survival (OS) rate. DFS = disease-free survival, LT = liver transplantation, OS = overall survival, SR = surgical resection.

Figure 4

Survival analysis stratified by the AFP level. (A–C) There was no difference in terms of overall survival (OS) when the AFP cutoff value was 200 ng/mL or 400 ng/mL. (D) Patients with an AFP ≥ 400 ng/mL had a better prognosis after LT than SR. AFP = alpha-fetoprotein, LT = liver transplantation, OS = overall survival, SR = surgical resection.

Figure 5

Survival analysis stratified by the PLT count. There was no difference in terms of overall survival (OS) when the PLT count cutoff value was 80 or 100 × 10⁹/L. OS = overall survival, PLT = platelet count.