Liver Transplantation or Resection for Treatment of Hepatocellular Carcinoma in Patients with Well-Compensated Cirrhosis: A Decision Analysis Model

Hepatocellular carcinoma (HCC) is a lethal tumor, for which liver resection and transplantation are the only potentially curative treatments. No prospective, randomized study has compared survival in patients with compensated cirrhosis after the two operations. Decision analysis modeling is an objective method to quantify risks and benefits. This study aimed to use decision analysis with a Markov model to estimate the impact of liver transplant and surgical resection on survival for patients with early stage (i.e., within Milan criteria) HCC and compensated cirrhosis. The model considered waitlist drop off due to tumor progression, the probability of tumor recurrence, and the impact of hepatitis C on post-transplant survival. Peri-operative mortality was estimated as 4% after resection and 7% after transplantation. The resection group had a 67% probability of tumor recurrence at 5 years and a median survival time after recurrence of 24 months. The transplant group had a 36% probability of tumor recurrence at 5 years, and a median survival time after recurrence of 8 months. The baseline analysis of this model revealed an overall survival benefit of 2.4 years for the transplant group over the resection group. Sensitivity analyses suggest that this survival benefit remains unless the probability of recurrence in the surgical resection group decreases to less than 50% at 5 years or the transplant waitlist time is longer than 27 months. In conclusion, considering the advantages and disadvantages of each surgical therapy, liver transplantation for HCC in patients with well compensated cirrhosis due to hepatitis C is associated with better overall survival than resection over a wide range of likely scenarios.