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Resection Is Best Option for Hepatocellular Carcinoma Patients with Child–Pugh A Cirrhosis

Key findings

  • This was a retrospective study of 206 patients with hepatocellular carcinoma and Child–Pugh A cirrhosis who met the Milan criteria for liver transplantation
  • There was no difference in overall survival between patients who underwent curative resection and those who received a transplant
  • The five-year overall survival rate following resection was 62%
  • Using the latest U.S. government cost data, the overall cost per patient was estimated to be about $100,000 higher for patients who had a transplant upfront than for those who had first-line resection, even when the cost of recurrence was considered

For patients with hepatocellular carcinoma (HCC) who are eligible for transplantation but have compensated cirrhosis, no strong evidence is available to guide the choice of treatment. In this subgroup, transplantation is associated with a substantial disease-free survival benefit, but the few studies available have not shown a clear benefit in terms of overall survival (OS). Most centers prioritize those patients for hepatectomy.

Theodoros Michelakos, MD, researcher and resident in the Department of Surgery at Massachusetts General Hospital, Cristina R. Ferrone, MD, surgical director of the Liver Program in the Division of General Surgery and the Mass General Cancer Center, and colleagues have confirmed that OS for these patients is similar to transplantation and resection. In the Journal of Gastrointestinal Surgery, they also calculate that transplantation is substantially more expensive, and they recommend considering resection as first-line treatment.

A Retrospective Cohort

The researchers reviewed patients with HCC who were treated surgically at Mass General between July 1992 and December 2015. In total, 206 had Child–Pugh A cirrhosis and met the Milan criteria for liver transplantation (solitary lesion ≤5 cm in diameter, or three tumors up to 3 cm each, with no portal vein involvement and no extrahepatic disease). They fell into three groups:

  1. 95 (46%) underwent hepatectomy
  2. 89 (43%) underwent liver transplantation
  3. 22 (11%) were listed for transplantation but died or had progressive disease

Resection vs. Transplantation

In an intention-to-treat analysis, OS from the time of diagnosis was statistically similar for the two treatments:


  • Median OS: 99 months
  • Three-year rate: 77%
  • Five-year rate: 62%
  • 10-year rate: 42%


  • Median OS: 122 months
  • Three-year rate: 76%
  • Five-year rate: 68%
  • 10-year rate: 52%

The size of the largest lesion was the only independent predictor of OS on multivariate analysis. The type of surgical treatment was not prognostic.

The results were similar when the analysis was limited to the 87% of patients who had surgery in 2002 or later, after implementation of the Model for End-stage Liver Disease point system.

Cost Analysis

The researchers compared the costs of the two kinds of treatment using recent federal data rather than Mass General data, in order to generate more widely applicable results.

Average Cost of the Principal Procedure

  • Resection: $28,492
  • Transplantation: $122,286

Preoperative Bridging Procedures

  • Resection group: 10 procedures
  • Transplantation group: 92 procedures

Postoperative Procedures to Treat Recurrence

  • Resection group: 41 procedures
  • Transplantation group: 1 procedure

Total Average Cost of Care

  • Resection: $37,391
  • Transplantation: $137,996

Considering the lack of improvement in survival with transplantation, the researchers question whether the substantial excess cost can be justified. With organ shortage being another important consideration, they advocate for resection as the first line of treatment for patients with HCC that meets the Milan criteria and Child–Pugh A cirrhosis.

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