Background: Liver transplantation (LT) is the optimal treatment option for hepatocellular carcinoma (HCC) meeting the Extended Liver Transplant Criteria (ELTC), but it is only offered for the minority. The optimal alternative strategy for HCCs beyond the Milan criteria (BMC) but meeting the ELTC, which is defined as modestly beyond the Milan criteria (MBMC) here, is a matter of concern. The aim of this study was to evaluate the survival benefits of LR compared with transarterial chemoembolization (TACE) for MBMC-HCCs.
Methods: From January 2010 to October 2021, from fifteen Chinese hepatobiliary centres, 1110 MBMC-HCC patients with Child‒Pugh A who underwent LR (n = 424) or TACE (n = 686) were included. Overall survival (OS) benefit of LR versus TACE in the MBMC-HCC cohort was compared based on a propensity score matching (PSM) and was further validated in addition BMC-HCC cohorts selected according to other extended LT criteria (Asan criteria, up-to-7 criteria, French alpha-foetoprotein model and Metroticket 2.0 model).
Results: Survival analyses in the MBMC-HCC cohort as well as other 4 BMC-HCC cohorts demonstrated that OS was significantly longer in the LR group than that in the TACE group (all log-rank P < 0.001). After a 1:1 PSM in the MBMC-HCC cohort, multivariate analysis and subsequent subgroup analyses based on tumour burden and other important covariates further confirmed the robust survival advantage of LR compared to TACE.
Conclusions: LR rather than TACE is highly recommended as the preferred alternative for potential LT candidates with MBMC-HCC regardless of tumor burden.