Intention-to-treat analysis of surgical treatment for early hepatocellularcarcinoma: Resection versus transplantation

Liver transplantation is proposed as the best therapy for early hepatocellu lar carcinoma in cirrhotic patients. However, the confrontation with the re sults obtained by surgical resection has never been done on an intention-to -treat basis. Between 1989 and 1997, 164 out of 1,265 patients with hepatoc ellular carcinoma were evaluated for surgery. Seventy-seven (48 men, mean 6 1 years of age, 74 Child-Pugh class A, size 33 +/- 18 mm) were resected (fi rst line option) and 87 (65 men, mean 55 years of age, 50 Child-Pugh class B/C, size 24 +/- 14 mm) were selected for transplantation. The 1-, 3-, and 5-year "intention-to-treat" survival was 85%, 62%, and 51% for resection an d 84%, 69%, and 69% for transplantation (8 drop-outs on waiting list). Bili rubin and clinically relevant portal hypertension were independent survival predictors after resection. Thereby, the 5-year survival of the best candi dates (absence of clinically relevant portal hypertension, n = 35) was 74%, whereas it was 25% for the worst candidates (portal hypertension and bilir ubin greater than or equal to 1 mg/dL, n = 27) (P < .00001). The variable " drop-out on waiting list" was the sole survival predictor after transplanta tion. The 2-year survival rate of patients evaluated for transplantation wa s 84% in the 1989 to 1995 period (mean waiting time, 62 days; no drop-outs) and 54% during 1996 to 1997 (mean waiting time, 162 days; 8 dropouts)(P < .003). This outcome was significantly lower than that of the best candidate s for resection (P = .002). In conclusion, a proper selection of candidates for resection promotes better results than transplantation, in which the r esults are significantly hampered by the growing incidence of drop-outs bec ause of the increasing waiting time.