Comparative analysis of outcome in patients with hepatocellular carcinoma exceeding the milan criteria treated with liver transplantation versus partial hepatectomy

Liver transplantation vs liver resection in HCC: promoting extensive collaborative research through a survival meta-analysis of meta-analyses

Background

HCC is a major global health concern, necessitating effective treatment strategies. This study conducts a meta-analysis of meta-analyses comparing liver resection (LR) and liver transplantation (LT) for HCC.

Methods

The systematic review included meta-analyses comparing liver resection vs. liver transplantation in HCC, following PRISMA guidelines. Primary outcomes included 5-year overall survival (OS) and disease-free survival (DFS). AMSTAR-2 assessed study quality. Citation matrix and hierarchical clustering validated the consistency of the included studies.

Results

A search identified 10 meta-analyses for inclusion. The median Pearson correlation coefficient for citations was 0.59 (IQR 0.41-0.65). LT showed better 5-year survival and disease-free survival in all HCC (OR): 0.79; 95% CI: 0.67-0.93, I^2:57% and OR: 0.44; 95% CI: 0.25-0.75, I^2:96%). Five-year survival in early HCC and ITT was 0.63 (95% CI: 0.50-0.78, I^2:0%) and 0.60 (95% CI: 0.39-0.92, I^2:0%). Salvage LT vs. Primary LT did not differ between 5-year survival and disease-free survival (OR: 0.62; 95% CI: 0.33-1.15, I^2:0% and 0.93; 95% CI: 0.82-1.04, I^2:0%).

Conclusion

Overall, the study underscores the superior survival outcomes associated with LT over LR in HCC treatment, supported by comprehensive meta-analysis and clustering analysis. There was no difference in survival or recurrence rate between salvage LT and primary LT. Therefore, considering the organ shortage, HCC can be resected and transplanted in case of recurrence.

Changes of long-term survival of resection and liver transplantation in hepatocellular carcinoma throughout the years: A meta-analysis

BACKGROUND

Hepatocellular Carcinoma (HCC) still is one of the most detrimental malignant diseases in the world. As two curative surgical therapies exist, the discussion whether to opt for liver resection (LR) or transplantation (LT) is ongoing, especially as novel techniques to improve outcome have emerged for both. The aim of the study was to investigate how the utilization and outcome of the respective modalities changed through time.

METHODS

We searched Medline and PubMed for relevant publications comparing LT and LR in HCC patients during the time period from 1990 to 2022, prior to March 31, 2023. A total of 63 studies involving 19,804 patients - of whom 8178 patients received a liver graft and 11,626 underwent partial hepatectomy - were included in this meta-analysis.

RESULTS

LT is associated with significantly better 5-year overall survival (OS) (64.83%) and recurrence-free survival (RFS) (70.20%) than LR (OS: 50.83%, OR: 1.79, p < 0.001; RFS: 34.46%, OR: 5.32, p < 0.001). However, these differences are not as evident in short-term intervals. Older cohorts showed comparable disparities between the outcome of the respective modalities, as did newer cohorts after 2005. This might be due to the similar improvement in survival rates that were observed for both, LT (15-23%) and LR (12-20%) during the last 30 years.

CONCLUSION

LT still outperforms LR in the therapy of HCC in terms of long-term survival rates. Yet, LR outcome has remarkably improved which is of major importance in reference to the well-known limitations that occur in LT.

Resection or Transplant in Early Hepatocellular Carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) has an incidence of 5-10 per 100 000 persons per year in the Western world. In 20% of cases, surgical liver resection (LR) or liver transplantation (LT) can be performed. LT results in longer survival, as it involves resection not only of the tumor, but of pre - cancerous tissue as well. The optimal allocation of donor organs depends on the identification of patients for whom LR is adequate treatment. In this meta-analysis, we compare LT and LR for patients with early HCC and wellcompensated cirrhosis.

METHODS

A systematic review of the pertinent literature was followed by a subgroup analysis of the studies in which patients with early HCC and wellcompensated cirrhosis were followed up after either LR or LT. Overall survival at 1, 3, and 5 years, as well as morbidity and mortality, were compared in a random effects meta-analysis.

RESULTS

54 studies with a total of 13 794 patients were included. Among patients with early HCC, the overall survival after LT became higher than the overall survival after LR 5 years after surgery (66.67% versus 60.35%, odds ratio 0.60 [0.45; 0.78], p <0.001); there was no significant difference 1 year or 3 years after surgery. Nor was there any significant difference in morbidity or mortality between the two types of treatment in this subgroup. These findings contrast with the results obtained in all of the studies, which documented significantly better survival 3 years after LT.

CONCLUSION

Three years after surgery, the survival rates and complication rates of patients with early HCC treated with either LR or LT are comparable. Resection should therefore be the preferred form of treatment if the prerequisites for it are met. In case of recurrent tumor, these patients can still be evaluated for liver transplantation. This strategy could improve the allocation of donor organs.

Liver transplantation vs liver resection in patients with HBV-related hepatocellular carcinoma beyond Milan criterion: A meta-analysis

OBJECTIVE

The aim of this study was to conduct a meta-analysis of published reports to compare long-term outcomes after liver transplantation (LT) and liver resection (LR), respectively, in patients with HBV-related hepatocellular carcinoma (HCC) beyond the Milan criterion.

METHODS

A systematic search of the Embase, Medline, PubMed databases, and the Cochrane Library was performed using both medical subject headings (MeSH) and truncated word searches to identify all comparative studies published on this topic. The primary outcomes were postoperative overall survival (OS) and disease-free survival (DFS). We calculated the pooled hazard ratios (HR) with 95% confidence intervals (95% CI) of OS and DFS.

RESULTS

Pooled analysis of six studies, with a total of 1697 patients with HCC beyond Milan criteria, did not reveal a statistically significant improvement in OS in patients undergoing LT vs LR (LT vs LR, HR: 0.83, 95% CI: 0.68-1.01, P = .06), without significant heterogeneity (χ²  = 8.38, I² = 40.3%, P = .137). Five studies with a total of 1511 patients were included in pooled analysis of DFS between LT and LR group. In the fixed-effects model, patients in the LT group gained significantly better DFS (LT vs LR, HR: 0.45, 95% CI: 0.37-0.56, P < .001) than patients in the LR group, with no significant heterogeneity (χ²  = 6.80, I² = 41.6%, P = .144). Four studies provided the data of adjusted HRs (LT vs LR). In the fixed-effects model, patients in the LT group had significantly better OS (HR: 0.58, 95% CI: 0.44-0.77, P < .001, I² = 0%) and DFS (HR: 0.14, 95% CI: 0.08-0.23, P < .001, I² = 0%) than those of patients in the LR group. The sensitivity analyses revealed that the results were robust.

CONCLUSION

Our meta-analysis demonstrated that HBV-related patients with HCC beyond Milan criterion who underwent LT gained better OS and DFS compared with patients who underwent LR after adjusting confounding factors.

Treatment of hepatocellular carcinoma in the community: disparities in standard therapy

BACKGROUND AND AIMS

Hepatocellular carcinoma (HCC) incidence is expected to rise dramatically over the next decades because of increasing hepatitis C infections and obesity-related comorbidities. However, little information exists regarding the treatment of patients with HCC in the community setting. The purpose of this article was to characterize patterns of diagnosis, treatment, and survival for HCC in the community.

METHODS

We identified 946 HCC patients in the 2007 National Cancer Institute's Patterns of Care study. Chi-square analyses and multivariable regression were used to examine patient and provider factors associated with treatment and survival by stage at diagnosis.

RESULTS

Our primary findings indicate that liver transplants, embolization, or radiofrequency ablation for Barcelona Clinic Liver Cancer stage A patients were performed significantly less often for non-Hispanic blacks, Hispanics, patients in the highest income quartile, and patients with Medicaid. Patients with stage D disease were less likely to receive cancer therapy if they had Medicaid insurance compared to private insurance (p<0.001 for all). In multivariable analyses, all-cause mortality was associated with treatment in a hospital without a residency training program (hazard ratio [HR] 1.4 [1.1,1.9]), more advanced stage (HR: 10.6 [5.7, 19.5] stage D vs. A), and lack of appropriate treatment (HR: 2.4 [1.9,3.2]).

CONCLUSIONS

This is the first population-based study to evaluate therapy provided for HCC in the community. Current therapy depended on patients' HCC stage at diagnosis and other clinical and demographic factors. Overall, our study identifies those least likely to receive specific therapies in a variety of health care settings and can inform strategies for promoting appropriate therapy now and as new agents are developed.

Liver transplantation versus liver resection in the treatment of hepatocellular carcinoma: a meta-analysis of observational studies

BACKGROUND

A number of cohort studies have compared the outcomes of liver transplantation (LT) and liver resection (LR) in hepatocellular carcinoma (HCC) patients. However, the effects of LT versus LR remain unclear. We searched electronic databases and reference lists for relevant articles published before February 2013.

METHODS

The primary endpoints were pooled using random-effects models to model potential heterogeneity, including overall survival (OS), disease-free survival, and recurrence rate.

RESULTS

We found similar 1-year OS (odds ratio [OR], 1.08; 95% confidence interval [CI], 0.81-1.43; P=0.61) yet significantly better 3-year OS (OR, 1.47; 95% CI, 1.18-1.84; P<0.001) and 5-year OS (OR, 1.77; 95% CI, 1.45-2.16; P<0.001) after LT compared with LR with relative risk differences of 9% (P<0.001) and 14% (P<0.001), respectively. The 1-, 3-, and 5-year difference-free survival were 13%, 29%, and 39% higher (P<0.001 in all) in LT recipients than LR patients. Additionally, recurrence rate was 30% less (P<0.001) in LT than LR. Furthermore, better 5-year difference-free survival (P<0.001) and recurrence rates (P<0.05) were yielded after LT when patients from the entire HCC population were included.

CONCLUSIONS

When including all the 62 previous studies comparing LT and resection, LT provides increased survival and lower recurrence rates than LR for HCC patients. These results of disease-free survival and recurrence rate are similar among early HCC patients with Child-Turcotte-Pugh class A cirrhosis. However, summary ORs and risk differences cannot be interpreted as causal effects of LT versus LR.

Hepatocellular cancer and liver transplantation: a Western experience

Orthotopic liver transplantation is the preferred treatment option in patients with hepatocellular carcinoma developing in chronic liver disease. Unfortunately, based on classical transplantation criteria (Milan criteria), only a minority of patients with hepatocellular carcinoma are candidate to orthotopic liver transplantation. Major improvements in treatment strategy and surgical technique including the use of neoadjuvant locoregional therapies and progresses of post-transplant immunosuppressive treatment have contributed to safely expand transplantation criteria preserving acceptable surgical morbidity-mortality and good oncologic outcome. Further extension of transplantation criteria may have advantages including an increase in the number of transplant candidates and improvement of the prognosis of the disease and also disadvantages including an increase of surgical morbidity and deterioration of global oncologic outcome of orthotopic liver transplantation in hepatocellular carcinoma. In the future, identification of imaging or molecular prognostic markers could help to better define transplantation criteria.

Comparison of outcomes of transplantation and resection in patients with early hepatocellular carcinoma: a meta-analysis

OBJECTIVES

Surgical decision making for patients with early hepatocellular carcinoma (HCC) and well-compensated cirrhosis remains controversial. The aim of the current study was to conduct a meta-analysis of published reports to compare survival outcomes after transplantation and resection, respectively, in patients with early HCC [i.e. HCC falling within the Milan Criteria (a solitary lesion measuring ≤5 cm or fewer than three lesions with a largest diameter of ≤3 cm, and absence of macroscopic vascular invasion or extrahepatic disease)] and well-compensated cirrhosis.

METHODS

A total of 990 abstracts were identified through a PubMed-based search. Ten articles comparing transplantation and resection in patients with early HCC were included in the meta-analysis. Meta-analysis was performed using stata 9.2 statistical software.

RESULTS

Outcomes were analysed for a total of 1763 patients with early HCC. The 5-year overall survival (OS) for all patients was 58% (transplantation: 63%; resection: 53%). Meta-analysis of all 10 studies revealed a survival advantage for transplantation [odds ratio (OR) 0.581, 95% confidence interval (CI) 0.359-0.939; P = 0.027]. Analysis of only those reports that utilized an 'intention-to-treat' strategy failed to demonstrate a survival advantage for either treatment approach (OR 0.600, 95% CI 0.291-1.237; P = 0.166).

CONCLUSIONS

The current study demonstrates a favourable outcome in patients with early HCC treated by either transplantation or resection. Although transplantation was noted to have a survival advantage in some settings, resection continues to be a viable treatment approach.

Improving Outcomes with Surgical Resection and Other Ablative Therapies in HCC

With rising incidence and emergence of effective treatment options, the management of hepatocellular carcinoma (HCC) is a complex multidisciplinary process. There is still little consensus and uniformity about clinicopathological staging systems. Resection and liver transplantation have been the cornerstone of curative surgical treatments with recent emergence of ablative techniques. Improvements in diagnostics, surgical techniques, and postoperative care have lead to dramatically improved results over the years. The most appropriate treatment plan has to be individualised and depends on a variety of patient and tumour-related factors. Very small HCCs discovered on surveillance have the best outcomes. Patients with advanced cirrhosis and tumours within Milan criteria should be offered transplantation. Resection is best for small solitary tumours with preserved liver function. Ablative techniques are suitable for low volume tumours in patients unfit for either resection or transplantation. The role of downstaging and bridging therapy is not clearly established.