Liver resection versus liver transplantation for hepatocellular carcinoma within the Milan criteria based on estimated microvascular invasion risks

Pinghua Yang; Fei Teng; Shilei Bai; Yong Xia; Zhihao Xie; Zhangjun Cheng; Jun Li; Zhengqing Lei; Kui Wang; Baohua Zhang; Tian Yang; Xuying Wan; Hao Yin; Hao Shen; Timothy M Pawlik; Wan Yee Lau; Zhiren Fu; Feng Shen

doi:10.1093/gastro/goad035

Liver resection versus liver transplantation for hepatocellular carcinoma within the Milan criteria based on estimated microvascular invasion risks

Gastroenterol Rep (Oxf). 2023 Jun 26:11:goad035. doi: 10.1093/gastro/goad035. eCollection 2023.

Authors

Pinghua Yang¹, Fei Teng², Shilei Bai¹, Yong Xia¹, Zhihao Xie¹, Zhangjun Cheng^{1

3}, Jun Li¹, Zhengqing Lei^{1

3}, Kui Wang⁴, Baohua Zhang⁵, Tian Yang⁴, Xuying Wan⁶, Hao Yin², Hao Shen¹, Timothy M Pawlik⁷, Wan Yee Lau^{1

8}, Zhiren Fu², Feng Shen¹

Affiliations

¹ Department of Hepatic Surgery IV and Clinical Research Institute, The Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, P. R. China.
² Department of Liver Surgery and Organ Transplantation, The Changzheng Hospital, Naval Medical University, Shanghai, P. R. China.
³ Department of General Surgery, The Affiliated Zhongda Hospital, Southeast University, Nanjing, Jiangsu, P. R. China.
⁴ Department of Hepatic Surgery II and Clinical Research Institute, The Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, P. R. China.
⁵ Department of Biliary Surgery IV and Clinical Research Institute, The Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, P. R. China.
⁶ Department of Chinese Traditional Medicine, The Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, P. R. China.
⁷ Department of Surgery, The Wexner Medical Center, Ohio State University, Columbus, OH, USA.
⁸ Faculty of Medicine, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong SAR, China.

Abstract

Background: Preoperative prediction of microvascular invasion (MVI) in hepatocellular carcinoma (HCC) may optimize individualized treatment decision-making. This study aimed to investigate the prognostic differences between HCC patients undergoing liver resection (LR) and liver transplantation (LT) based on predicted MVI risks.

Methods: We analysed 905 patients who underwent LR, including 524 who underwent anatomical resection (AR) and 117 who underwent LT for HCC within the Milan criteria using propensity score matching. A nomogram model was used to predict preoperative MVI risk.

Results: The concordance indices of the nomogram for predicting MVI were 0.809 and 0.838 in patients undergoing LR and LT, respectively. Based on an optimal cut-off value of 200 points, the nomogram defined patients as high- or low-risk MVI groups. LT resulted in a lower 5-year recurrence rate and higher 5-year overall survival (OS) rate than LR among the high-risk patients (23.6% vs 73.2%, P < 0.001; 87.8% vs 48.1%, P < 0.001) and low-risk patients (19.0% vs 45.7%, P < 0.001; 86.5% vs 70.0%, P = 0.002). The hazard ratios (HRs) of LT vs LR for recurrence and OS were 0.18 (95% confidence interval [CI], 0.09-0.37) and 0.12 (95% CI, 0.04-0.37) among the high-risk patients and 0.37 (95% CI, 0.21-0.66) and 0.36 (95% CI, 0.17-0.78) among the low-risk patients. LT also provided a lower 5-year recurrence rate and higher 5-year OS rate than AR among the high-risk patients (24.8% vs 63.5%, P = 0.001; 86.7% vs 65.7%, P = 0.004), with HRs of LT vs AR for recurrence and OS being 0.24 (95% CI, 0.11-0.53) and 0.17 (95% CI, 0.06-0.52), respectively. The 5-year recurrence and OS rates between patients undergoing LT and AR were not significantly different in the low-risk patients (19.4% vs 28.3%, P = 0.129; 85.7% vs 77.8%, P = 0.161).

Conclusions: LT was superior to LR for patients with HCC within the Milan criteria with a predicted high or low risk of MVI. No significant differences in prognosis were found between LT and AR in patients with a low risk of MVI.

Keywords: hepatocellular carcinoma; liver resection; liver transplantation; microvascular invasion; prognosis.