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Liver Resection vs Transplantation for Patients with Hepatocellular Carcinoma Beyond Milan Criteria
Victor M Zaydfudim*1, Neeta Vachharajani*2, Goran B Klintmalm3, William R Jarnagin4, Alan W Hemming5, Maria B Majella Doyle*2, Keith M Cavaness*3, William C Chapman2, David M Nagorney6
1University of Virginia, Charlottesville, VA;2Washington University School of Medicine, St. Louis, MO;3Baylor University Medical Center, Dallas, TX;4Memorial Sloan-Kettering Cancer Center, New York, NY;5University of California San Diego, San Diego, CA;6Mayo Clinic, Rochester, MN

Objectives: Both liver resection and transplantation remain controversial for patients with hepatocellular carcinoma (HCC) beyond Milan Criteria. Resections of advanced tumors and transplantation using extended-criteria are pursued at select high-volume center. This study compares survival between liver resection and transplantation for patients with HCC beyond Milan Criteria.
Methods: Patients from 5 liver cancer centers in the United States who had liver resection or transplantation for HCC beyond Milan Criteria between 1990 and 2011 were included in the study. Propensity-matching and multivariable analyses estimated the effects of clinical factors and operative selection on survival.
Results: Of 608 patients beyond Milan without vascular invasion, 480 (79%) underwent resection and 128 (21%) underwent transplantation. Hepatitis C and cirrhosis were more prevalent in transplantation group (p<0.001). Resection patients had larger tumors (10±4 versus 5±2 cm, p<0.001); transplant patients were more likely to have multiple tumors (78% versus 28%, p<0.001). Overall (OS) and recurrence-free survival (RFS) were both better after transplantation than resection (p<0.001). Both, patients treated with TACE prior to transplant (51%) and patients who were untreated or failed to downstage (49%) had better OS and RFS compared to resection (all p≤0.024). After adjustment for effects of age, tumor size and number, liver transplantation was associated with improved overall (HR=0.48; 95%CI:0.33-0.69, p<0.001) and recurrence-free (HR=0.31, 95%CI:0.22-0.44, p<0.001) survival.
Conclusions: Liver transplantation is associated with improved overall and recurrence-free survival in patients with HCC beyond Milan Criteria. Treatment strategies aimed at tumor downstaging and expansion of transplantation could improve outcomes in patients with advanced HCC.


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