Partial hepatectomy or orthotopic liver transplantation for the treatment of resectable hepatocellular carcinoma? A cost-effectiveness perspective

Abstract

The treatment of patients with compensated liver cirrhosis and small hepatocarcinomas remains controversial. Whereas partial hepatectomy (PH) is currently recommended, the role of orthotopic liver transplantation (OLT) has become progressively accepted. We used the techniques of decision analysis to measure the clinical benefits and the economic consequences of immediate resection versus transplantation in patients with compensated cirrhosis and who were diagnosed with small hepatocellular carcinoma (HCC). We restricted our analysis to patients with resectable carcinomas, which is either solitary tumor (I 5 cm in diameter), or multiple tumors (up to 3), none being G 3 cm in diameter and, in both cases, no tumor invasion of blood vessels. We took into account the risks of tumor spreading and dissemination and/or development of decompensated cirrhosis while waiting for donor organs because organ shortage is presented as the main obstacle to transplantation in these patients. Our analysis suggests that orthotopic liver transplantation (OLT) offers a substantial survival benefit compared with resection, ranging from a minimum of 1 year to a maximum of 4.7 years depending on treatment-related survival rates. However, the magnitude of this benefit relies on the availability of an organ donor; therefore, if the waiting period exceeds 6 to 10 months, depending on tumor growth pattern, the increase in life expectancy provided by transplantation is overwhelmed by the risks that patients face while waiting for transplantation. Consequently, partial resection becomes the preferred strategy. The predicted marginal cost-effectiveness ratios of transplantation compared with resection would range between $44,454 and $183,840 per additional year gained mainly influenced by the time delay before getting a transplant. We conclude that compared with partial hepatectomy (PH), OLT for resectable hepatocarcinoma(s) offers substantial survival benefit among well-targeted subgroups of patients as long as an organ donor is available within a maximal 6 to 10 months time delay, which is a plausible scenario in most centers with a liver transplant program.However, the marginal cost-effectiveness ratios incurred by this strategy are higher than that of many other current medical interventions. (HEPATOLOGY 1998;28:436-442.)For most patients with cirrhosis, hepatocellular carcinoma (HCC) presents as an advanced tumor. In this setting, palliation is the only option and, consequently, patients survive for only a few months. Nonetheless, some of them with small curable HCC will be recognized at an earlier stage, either incidentally, or through screening programs. 1 In this latter subgroup, representing approximately 10% of diagnosed HCC, there is considerable controversy about the best treatment modality. 2,3,4,5,6 Until recently, the current approach was to recommend surgical resection in the form of PH (segmentary or subsegmentary resection), with 5-year survival rates achieving 40% to 50% when this policy was restricted to patients with uninod...

Primary liver resection and salvage transplantation or primary liver transplantation in patients with single, small hepatocellular carcinoma and preserved liver function: An outcome-oriented decision analysis

“…This has been suggested in a previous study from our unit. 2 Our study focused on patients with single small tumors and compensated cirrhosis because in these patients both liver resection and OLT are accepted as primary treatments. Given the high recurrence rate of HCC after partial hepatectomy, however, treatment by liver resection alone, without the possibility of rescue by transplantation, gives a suboptimal survival benefit, and we did not consider it as a realistic possibility in our analysis.…”

“…1 In patients aged less than 65 years, 2 therapies are currently accepted for early HCC (Յ5 cm): partial hepatectomy (PH) and orthotopic liver transplantation (OLT). 2,3 Although studies comparing the 2 treatments are retrospective and concern patients with disparate tumor characteristics and liver function, [4][5][6] it is agreed that OLT is preferable to partial hepatectomy in patients with hepatic insufficiency and in patients with more than 1 tumor, in whom the results of liver resection are poor.…”

“…The tumor, however, can outgrow the criteria accepted for transplantation while waiting for donor organs, affecting the ultimate outcome as shown in a previous analysis. 2 For patients with a single resectable HCC, an alternative strategy to either partial hepatectomy or OLT would be to offer resection first and transplantation if the tumor recurs or if the liver function deteriorates (salvage OLT). Before such a strategy can be tested in a prospective controlled trial, the present study examines its implications in terms of patient outcome, graft use, and costs, using a decisional analysis model based on the data available in the literature.…”

Current management strategy of hepatocellular carcinoma

“…As a result, these patients should be removed from the waiting list, indeed about 50% of HCC patients who were initially candidates for LT will become ineligible for transplantation if the median waiting period exceeds 1 year [53,56] .…”

Role of adult living liver donation in patients with hepatocellular cancer

“…[2][3][4] One of the major downfalls of transplantation as a treatment for HCC is that patients must wait for a liver. This waiting time compromises the outcome for transplantation as compared with that for immediate resection 5,6 (Fig. 2).…”