Hepatocellular Carcinoma in Transplantable Child-Pugh A Cirrhotics: Should Cost Affect Resection vs Transplantation?

Theodoros Michelakos, Dimitrios Xourafas, Motaz Qadan, Rafael Pieretti-Vanmarcke, Lei Cai, Madhukar S. Patel, Joel T. Adler, Fermin Fontan, Usama Basit, Parsia A. Vagefi, Nahel Elias, Kenneth K. Tanabe, David Berger, Heidi Yeh, James F. Markmann, David C. Chang, Cristina R. Ferrone

Research output: Contribution to journalArticle

Abstract

Background: There is no consensus regarding the optimal surgical treatment for transplantable hepatocellular carcinoma (HCC) patients with well-compensated cirrhosis. Our aim was to compare outcomes between Child-Pugh A (CPA) cirrhotics who underwent liver resection or transplantation for HCC. Methods: Clinicopathologic data were retrospectively collected for all surgically treated HCC patients between 7/1992 and 12/2015. Disease-free survival (DFS) and overall survival (OS) were calculated from the time of operation or diagnosis (intention-to-treat analysis including patients removed from the transplant list). The average overall cost including pre-operative and post-operative procedures was calculated for each group. Results: Of the 513 surgically treated HCC patients, 184 had CPA cirrhosis and fulfilled the Milan criteria (MC). Of those, 95 (52%) were resected and 89 (48%) were transplanted. Twenty-two patients were removed from the transplant list. Transplanted patients were younger (p < 0.001), had a higher MELD score (p < 0.001) and a higher frequency of hepatitis C (p < 0.001). Length of stay and postoperative complication rates were similar between groups. DFS was longer for transplanted patients (3-, 5-, and 10-year DFS rates 48, 44, 31% vs 96, 94, 94%, respectively, p < 0.001). OS was similar between groups (3-, 5-, and 10-year OS rates 76, 62, 41% vs 82, 77, 53%, respectively, p = 0.07). Only size of greatest lesion and T stage were independent predictors of OS. The cost was much higher for the transplant group, even when accounting for the treatment of recurrences ($37,391 vs $137,996). Conclusions: Since OS is similar between CPA cirrhotics within the MC undergoing resection or transplantation for HCC, but cost is significantly higher for transplantation. Resection should be considered for first-line treatment.

Original languageEnglish (US)
Pages (from-to)1135-1142
Number of pages8
JournalJournal of Gastrointestinal Surgery
Volume23
Issue number6
DOIs
StatePublished - Jun 15 2019

Keywords

  • Cirrhosis
  • Healthcare cost
  • Hepatectomy
  • Hepatocellular carcinoma
  • Transplantation

ASJC Scopus subject areas

  • Surgery
  • Gastroenterology

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    Michelakos, T., Xourafas, D., Qadan, M., Pieretti-Vanmarcke, R., Cai, L., Patel, M. S., Adler, J. T., Fontan, F., Basit, U., Vagefi, P. A., Elias, N., Tanabe, K. K., Berger, D., Yeh, H., Markmann, J. F., Chang, D. C., & Ferrone, C. R. (2019). Hepatocellular Carcinoma in Transplantable Child-Pugh A Cirrhotics: Should Cost Affect Resection vs Transplantation? Journal of Gastrointestinal Surgery, 23(6), 1135-1142. https://doi.org/10.1007/s11605-018-3946-z