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. 2022 Feb;11(1):78-93.
doi: 10.21037/hbsn-21-350.

Liver resection versus liver transplantation for hepatocellular carcinoma within Milan criteria: a meta-analysis of 18,421 patients

Jin Hean Koh #  1 , Darren Jun Hao Tan #  1 , Yuki Ong  1 , Wen Hui Lim  1 , Cheng Han Ng  1 , Phoebe Wen Lin Tay  1 , Jie Ning Yong  1 , Mark D Muthiah  1   2   3 , Eunice X Tan  1   2   3 , Ning Qi Pang  3   4 , Beom Kyung Kim  5   6 , Nicholas Syn  1   7 , Alfred Kow  3   4 , Brian K P Goh  8   9 , Daniel Q Huang  1   2   3
Affiliations

Liver resection versus liver transplantation for hepatocellular carcinoma within Milan criteria: a meta-analysis of 18,421 patients

Jin Hean Koh et al. Hepatobiliary Surg Nutr. 2022 Feb.

Abstract

Background: Outcomes after liver resection (LR) and liver transplantation (LT) for hepatocellular carcinoma (HCC) are heterogenous and may vary by region, over time periods and disease burden. We aimed to compare overall survival (OS) and disease-free survival (DFS) between LT versus LR for HCC within the Milan criteria.

Methods: Two authors independently searched Medline and Embase databases for studies comparing survival after LT and LR for patients with HCC meeting the Milan criteria. Meta-analyses and metaregression were conducted using random-effects models.

Results: We screened 2,278 studies and included 35 studies with 18,421 patients. LR was associated with poorer OS [hazard ratio (HR) =1.44; 95% confidence interval (CI): 1.14-1.81; P<0.01] and DFS (HR =2.71; 95% CI: 2.23-3.28; P<0.01) compared to LT, with similar findings among intention-to-treat (ITT) studies. In uninodular disease, OS in LR was comparable to LT (P=0.13) but DFS remained poorer (HR =2.95; 95% CI: 2.30-3.79; P<0.01). By region, LR had poorer OS versus LT in North America and Europe (P≤0.01), but not Asia (P=0.25). LR had inferior survival versus LT in studies completed before 2010 (P=0.01), but not after 2010 (P=0.12). Cohorts that underwent enhanced surveillance had comparable OS after LT and LR (P=0.33), but cohorts undergoing usual surveillance had worse OS after LR (HR =1.95; 95% CI: 1.24-3.07; P<0.01).

Conclusions: Mortality after LR for HCC is nearly 50% higher compared to LT. Survival between LR and LT were similar in uninodular disease. The risk of recurrence after LR is threefold that of LT.

Keywords: Hepatocellular carcinoma (HCC); liver resection (LR); liver transplant; recurrence; survival.

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Conflict of interest statement

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-21-350/coif). The authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1
PRISMA flow diagram for included articles. LT, liver transplantation; LR, liver resection; HCC, hepatocellular carcinoma; PRISMA, Preferred Reporting Items for Systematic Review and Meta-Analyses.
Figure 2
Figure 2
Forest plot for OS among patients who underwent LR versus LT for HCC. HR, hazard ratio; CI, confidence interval; OS, overall survival; LR, liver resection; LT, liver transplantation; HCC, hepatocellular carcinoma.
Figure 3
Figure 3
Forest plot for OS among patients who underwent LR versus LT, by surveillance strategy. HR, hazard ratio; CI, confidence interval; OS, overall survival; LR, liver resection; LT, liver transplantation.
Figure 4
Figure 4
Forest plot for DFS among patients who underwent LR versus LT for HCC. HR, hazard ratio; CI, confidence interval; DFS, disease-free survival; LR, liver resection; LT, liver transplantation; HCC, hepatocellular carcinoma.
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