Is resection or transplantation the ideal treatment in patients with hepatocellular carcinoma in cirrhosis if both are possible? A systematic review and metaanalysis.

BACKGROUND: Hepatocellular carcinoma (HCC) is one of the most common neoplasms. Curative treatment options include liver resection (LR) and transplantation (LT). Organ shortage leads to discussion whether resectable HCC in cirrhosis should undergo LT or LR.
METHODS: Systematic review and metaanalysis of studies investigating LR and/or LT were performed. Overall survival (OS) and disease-free survival (DFS) were analyzed. Studies reporting 5-year OS of LR versus LT in an intention-to-treat fashion were included in a metaanalysis.
RESULTS: No randomized controlled trial was detected. Seventy publications were eligible for analysis. The 5-year OS revealed a better outcome for LT than LR (60.9 vs. 49.4 %; p < 0.001). Descriptive DFS data indicate superiority of LT at 3 years (62.0 vs. 45.9 %; p < 0.001) and 5 years (58 vs. 33.9 %; p < 0.001). Comparing the 5-year OS of transplantation and resection in a metaanalysis by use of the seven studies with a total of 1,572 patients, no survival advantage could be found (odds ratio, 0.84; 95 % confidence interval, 0.48-1.48; p = 0.55).
CONCLUSIONS: A low quality of evidence data suggests the following: resectable HCC should primarily be resected as good alternative to liver transplantation in patients in whom both seem feasible. Randomized controlled trials or at least systematic evaluation of a cohort of patients in which resection and transplantation seem possible should be performed in a registry. This analysis should include intention-to-treat analysis of patients on the waiting list who do not proceed to a potential curative treatment.