Long-Term Survival and Recurrence After Liver Transplantation Versus Resection in Cirrhotic Hepatocellular Carcinoma: A Systematic Review

Abstract

This systematic review evaluates and compares the long-term survival and recurrence outcomes of liver transplantation (LT) versus liver resection (LR) in patients with hepatocellular carcinoma (HCC) and underlying cirrhosis. A comprehensive search was conducted in accordance with PRISMA guidelines across PubMed, Embase, and the Cochrane Library, yielding 415 articles, of which four high-quality meta-analyses were included based on predefined eligibility criteria. The included studies encompassed tens of thousands of patients and consistently demonstrated that LT offers superior overall survival (OS) and disease-free survival (DFS), along with significantly lower recurrence rates, when compared to LR. Subgroup analyses revealed that the survival advantage of LT is more pronounced in patients within the Milan criteria or those with multifocal disease, while outcomes of LR improved over time, particularly in cases with solitary tumors and structured postoperative surveillance. The review also highlights the influence of geographic disparities, institutional practices, and healthcare resource availability on treatment selection and outcomes. Quality assessment using the AMSTAR 2 tool confirmed that three studies were of high quality with low risk of bias, while one was of moderate quality. These findings support the use of LT as the preferred treatment for eligible patients, while acknowledging LR as a valuable alternative in specific clinical scenarios, particularly where organ availability is limited.

Keywords: cirrhosis; disease-free survival; hepatocellular carcinoma; liver resection; liver transplantation; long-term survival; meta-analysis; milan criteria; recurrence; systematic review.

Figure 1. The PRISMA flowchart represents the study selection process.

PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses