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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
Original Article
  • 38 Downloads

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.

Keywords

Hepatocellular carcinoma Hepatectomy Transplantation Cirrhosis Healthcare cost 

Notes

Author Contributions

All authors approved the version to be published and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. T.M. was involved in the conception and design of the study; the acquisition, analysis, and interpretation of data; and drafted the manuscript. D.X. participated in the design of the study; acquisition, analysis, and interpretation of the data; and drafted and revised the manuscript. M.Q. was involved in the conception and design of the study; the acquisition, analysis, and interpretation of data; and revised the manuscript critically for important intellectual content. R.P.-V. was involved in the conception and design of the study; the acquisition, analysis, and interpretation of data; and revised the manuscript critically for important intellectual content. L.C. was involved in the conception and design of the study; the acquisition, analysis, and interpretation of data; and drafted the manuscript. M.S.P. participated in the design of the study, analysis and interpretation of the data, and revised the manuscript critically for important intellectual content. J.T.A. participated in the design of the study, analysis and interpretation of the data, and revised the manuscript critically for important intellectual content. F.F. participated in the design of the study, analysis and interpretation of the data, and revised the manuscript critically for important intellectual content. U.B. participated in the design of the study, analysis and interpretation of the data, and revised the manuscript critically for important intellectual content. P.A.V. was involved in the design of the study, the acquisition and interpretation of data, and revised the manuscript critically for important intellectual content. N.E. was involved in the conception and design of the study, the acquisition and interpretation of data, and drafted and revised the manuscript. K.K.T. participated in the design of the study, analysis and interpretation of the data, and revised the manuscript critically for important intellectual content. D.B. was involved in the design of the study, the acquisition and interpretation of data, and revised the manuscript critically for important intellectual content. H.Y. was involved in the conception and design of the study; the acquisition, analysis, and interpretation of data; and drafted the manuscript. J.F.M. was involved in the conception and design of the study; the acquisition, analysis, and interpretation of data; and revised the manuscript critically for important intellectual content. D.C.C. was involved in the conception and design of the study; the acquisition, analysis, and interpretation of data; and drafted the manuscript. C.R.F. was involved in the conception and design of the study; the acquisition, analysis, and interpretation of data; and drafted and revised the manuscript critically for important intellectual content.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

References

  1. 1.
    Altekruse SF, McGlynn KA, Reichman ME. Hepatocellular carcinoma incidence, mortality, and survival trends in the United States from 1975 to 2005. J Clin Oncol 2009;27:1485–1491.CrossRefPubMedCentralGoogle Scholar
  2. 2.
    El-Serag HB. Hepatocellular carcinoma: an epidemiologic view. J Clin Gastroenterol 2002;35:S72–78.CrossRefPubMedCentralGoogle Scholar
  3. 3.
    Monto A, Wright TL. The epidemiology and prevention of hepatocellular carcinoma. Semin Oncol 2001;28:441–449.CrossRefPubMedCentralGoogle Scholar
  4. 4.
    Siegel RL, Miller KD, Jemal A. Cancer Statistics, 2017. CA Cancer J Clin 2017;67:7–30.CrossRefPubMedCentralGoogle Scholar
  5. 5.
    Shuto T, Hirohashi K, Kubo S, et al. Changes and results of surgical strategies for hepatocellular carcinoma: results of a 15-year study on 452 consecutive patients. Surg Today 1998;28:1124–1129.CrossRefPubMedCentralGoogle Scholar
  6. 6.
    Zhou XD, Tang ZY, Yang BH, et al. Experience of 1000 patients who underwent hepatectomy for small hepatocellular carcinoma. Cancer 2001;91:1479–1486.CrossRefPubMedCentralGoogle Scholar
  7. 7.
    Fan ST, Mau Lo C, Poon RT, et al. Continuous improvement of survival outcomes of resection of hepatocellular carcinoma: a 20-year experience. Ann Surg 2011;253:745–758.CrossRefPubMedCentralGoogle Scholar
  8. 8.
    Llovet JM, Bruix J, Fuster J, et al. Liver transplantation for small hepatocellular carcinoma: the tumor-node-metastasis classification does not have prognostic power. Hepatology 1998;27:1572–1577.CrossRefPubMedCentralGoogle Scholar
  9. 9.
    Mazzaferro V, Regalia E, Doci R, et al. Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis. N Engl J Med 1996;334:693–699.CrossRefPubMedCentralGoogle Scholar
  10. 10.
    Itamoto T, Nakahara H, Tashiro H, et al. Indications of partial hepatectomy for transplantable hepatocellular carcinoma with compensated cirrhosis. Am J Surg 2005;189:167–172.CrossRefPubMedCentralGoogle Scholar
  11. 11.
    Tanabe KK. New techniques of liver surgery. Semin Oncol 2006;33:S39–41.CrossRefPubMedCentralGoogle Scholar
  12. 12.
    Yao FY, Ferrell L, Bass NM, et al. Liver transplantation for hepatocellular carcinoma: expansion of the tumor size limits does not adversely impact survival. Hepatology 2001;33:1394–1403.CrossRefPubMedCentralGoogle Scholar
  13. 13.
    Forner A, Reig M, Bruix J. Hepatocellular carcinoma. Lancet 2018;391:1301–1314.CrossRefPubMedCentralGoogle Scholar
  14. 14.
    Proneth A, Zeman F, Schlitt HJ, et al. Is resection or transplantation the ideal treatment in patients with hepatocellular carcinoma in cirrhosis if both are possible? A systematic review and metaanalysis. Ann Surg Oncol 2014;21:3096–3107.CrossRefPubMedCentralGoogle Scholar
  15. 15.
    Kamath PS, Wiesner RH, Malinchoc M, et al. A model to predict survival in patients with end-stage liver disease. Hepatology 2001;33:464–470.CrossRefGoogle Scholar
  16. 16.
    HCUP National Inpatient Sample (NIS). Healthcare Cost and Utilization Project (HCUP) [database online]. Insert City of Publication Here see notes; 2012.Google Scholar
  17. 17.
    Price RA, Stranges E, Elixhauser A. Cancer Hospitalizations for Adults, 2009: Statistical Brief #125. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD); 2006.Google Scholar
  18. 18.
    Makuuchi M, Kosuge T, Takayama T, et al. Surgery for small liver cancers. Semin Surg Oncol 1993;9:298–304.CrossRefPubMedCentralGoogle Scholar
  19. 19.
    Torzilli G, Makuuchi M, Inoue K, et al. No-mortality liver resection for hepatocellular carcinoma in cirrhotic and noncirrhotic patients: is there a way? A prospective analysis of our approach. Arch Surg 1999;134:984–992.CrossRefPubMedCentralGoogle Scholar
  20. 20.
    Jaeck D, Bachellier P, Oussoultzoglou E, et al. Surgical resection of hepatocellular carcinoma. Post-operative outcome and long-term results in Europe: an overview. Liver Transpl 2004;10:S58–63.CrossRefPubMedCentralGoogle Scholar
  21. 21.
    Bismuth H, Majno P, Adam R. Hepatocellular carcinoma: from ethanol injection to liver transplantation. Acta Gastroenterol Belg 1999;62:330–341.PubMedPubMedCentralGoogle Scholar
  22. 22.
    Katz SC, Shia J, Liau KH, et al. Operative blood loss independently predicts recurrence and survival after resection of hepatocellular carcinoma. Ann Surg 2009;249:617–623.CrossRefPubMedCentralGoogle Scholar
  23. 23.
    Belghiti J, Panis Y, Farges O, et al. Intrahepatic recurrence after resection of hepatocellular carcinoma complicating cirrhosis. Ann Surg 1991;214:114–117.CrossRefPubMedCentralGoogle Scholar
  24. 24.
    Nagasue N, Kohno H, Chang YC, et al. Liver resection for hepatocellular carcinoma. Results of 229 consecutive patients during 11 years. Ann Surg 1993;217:375–384.CrossRefPubMedCentralGoogle Scholar
  25. 25.
    Poon RT, Fan ST, Lo CM, et al. Long-term survival and pattern of recurrence after resection of small hepatocellular carcinoma in patients with preserved liver function: implications for a strategy of salvage transplantation. Ann Surg 2002;235:373–382.CrossRefPubMedCentralGoogle Scholar
  26. 26.
    Cherqui D, Laurent A, Mocellin N, et al. Liver resection for transplantable hepatocellular carcinoma: long-term survival and role of secondary liver transplantation. Ann Surg 2009;250:738–746.CrossRefPubMedCentralGoogle Scholar
  27. 27.
    Dhir M, Melin AA, Douaiher J, et al. A Review and Update of Treatment Options and Controversies in the Management of Hepatocellular Carcinoma. Ann Surg 2016;263:1112–1125.CrossRefPubMedCentralGoogle Scholar
  28. 28.
    Centers for Medicare & Medicaid Services OotA. National Health Expenditure Projections 2016–2025 2017. Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsProjected.html. Accessed October 15, 2017, 2017.

Copyright information

© The Society for Surgery of the Alimentary Tract 2018

Authors and Affiliations

  • Theodoros Michelakos
    • 1
  • Dimitrios Xourafas
    • 1
  • Motaz Qadan
    • 1
  • Rafael Pieretti-Vanmarcke
    • 1
  • Lei Cai
    • 1
  • Madhukar S. Patel
    • 1
  • Joel T. Adler
    • 2
  • Fermin Fontan
    • 1
  • Usama Basit
    • 1
  • Parsia A. Vagefi
    • 1
    • 3
  • Nahel Elias
    • 1
  • Kenneth K. Tanabe
    • 1
  • David Berger
    • 1
  • Heidi Yeh
    • 1
  • James F. Markmann
    • 1
  • David C. Chang
    • 1
  • Cristina R. Ferrone
    • 1
  1. 1.Department of Surgery, Massachusetts General HospitalHarvard Medical SchoolBostonUSA
  2. 2.Department of SurgeryUniversity of WisconsinMadisonUSA
  3. 3.Department of Surgery, UT SouthwesternDallasUSA

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