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. 2019 Jun;23(6):1135-1142.
doi: 10.1007/s11605-018-3946-z. Epub 2018 Sep 14.

Hepatocellular Carcinoma in Transplantable Child-Pugh A Cirrhotics: Should Cost Affect Resection vs Transplantation?

Theodoros Michelakos  1 , Dimitrios Xourafas  1 , Motaz Qadan  1 , Rafael Pieretti-Vanmarcke  1 , Lei Cai  1 , Madhukar S Patel  1 , Joel T Adler  2 , Fermin Fontan  1 , Usama Basit  1 , Parsia A Vagefi  1   3 , Nahel Elias  1 , Kenneth K Tanabe  1 , David Berger  1 , Heidi Yeh  1 , James F Markmann  1 , David C Chang  1 , Cristina R Ferrone  4
Affiliations

Hepatocellular Carcinoma in Transplantable Child-Pugh A Cirrhotics: Should Cost Affect Resection vs Transplantation?

Theodoros Michelakos et al. J Gastrointest Surg. 2019 Jun.

Abstract

Background: There is no consensus regarding the optimal surgical treatment for transplantable hepatocellular carcinoma (HCC) patients with well-compensated cirrhosis. Our aim was to compare outcomes between Child-Pugh A (CPA) cirrhotics who underwent liver resection or transplantation for HCC.

Methods: Clinicopathologic data were retrospectively collected for all surgically treated HCC patients between 7/1992 and 12/2015. Disease-free survival (DFS) and overall survival (OS) were calculated from the time of operation or diagnosis (intention-to-treat analysis including patients removed from the transplant list). The average overall cost including pre-operative and post-operative procedures was calculated for each group.

Results: Of the 513 surgically treated HCC patients, 184 had CPA cirrhosis and fulfilled the Milan criteria (MC). Of those, 95 (52%) were resected and 89 (48%) were transplanted. Twenty-two patients were removed from the transplant list. Transplanted patients were younger (p < 0.001), had a higher MELD score (p < 0.001) and a higher frequency of hepatitis C (p < 0.001). Length of stay and postoperative complication rates were similar between groups. DFS was longer for transplanted patients (3-, 5-, and 10-year DFS rates 48, 44, 31% vs 96, 94, 94%, respectively, p < 0.001). OS was similar between groups (3-, 5-, and 10-year OS rates 76, 62, 41% vs 82, 77, 53%, respectively, p = 0.07). Only size of greatest lesion and T stage were independent predictors of OS. The cost was much higher for the transplant group, even when accounting for the treatment of recurrences ($37,391 vs $137,996).

Conclusions: Since OS is similar between CPA cirrhotics within the MC undergoing resection or transplantation for HCC, but cost is significantly higher for transplantation. Resection should be considered for first-line treatment.

Keywords: Cirrhosis; Healthcare cost; Hepatectomy; Hepatocellular carcinoma; Transplantation.

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