Li Wei, Xiao Haitao, Wu Hong, Xu Xuewen, Zhang Yange
Department of Plastic and Burns Surgery, West China Hospital, Sichuan University, Chengdu, China.
Department of Liver Surgery & Liver Transplantation Center, West China Hospital, Sichuan University, Chengdu, China.
Front Oncol. 2021 May 26;11:592835. doi: 10.3389/fonc.2021.592835. eCollection 2021.
This study aimed to compare the long-term outcomes of liver transplantation (LT) and liver resection (LR) among patients with stage I and II hepatocellular carcinoma (HCC).
SEER 18 registry from 2004 to 2015 was retrieved for this study. We included 1,765 and 1,746 cases with stage I-II (AJCC, 7) HCC in the multivariable analyses and instrumental variable (IV) analyses, respectively. Propensity score matching (PSM) was further carried out to ensure comparability. Propensity score to receive LT was adjusted by stabilized inverse probability of treatment weighting (IPTW) and standardized mortality ratio weighting (SMRW) methods. In addition, IV analysis was performed to adjust both measured and unmeasured confounding factors.
We identified 1,000 (56.7%) and 765 (43.3%) patients treated with LR and LT, respectively. In the multivariable adjusted cohort, after adjusting potential confounders, patients undergoing LT offered significant prognostic advantages over LR in overall survival (OS, P < 0.001) and disease-free survival (DSS, P < 0.001). The instrument variable in this study is LT rates in various Health Service Areas (HSAs). Results from the IV analysis showed that cases treated with LT had significantly longer OS (P = 0.001) and DSS (P < 0.001). In IV analysis stratified by clinicopathologic variables, the treatment effect of LT LR in OS was consistent across all subgroups. Regarding DSS in IV analyses, the subgroup analyses observed that LT had better DSS across all subgroups, except for similar results in the older patients (interaction P value = 0.039) and the non-White patients (interaction P value = 0.041). In the propensity-matched cohort, patients with LT still had better OS (P < 0.001) and DSS (P < 0.001) in comparison to cases who underwent LR. In both IPTW and SMRW cohorts, patients who underwent LT had better OS (both P values < 0.001) and DSS (both P values < 0.001).
LT provided a survival benefit for cases with stage I-II HCC. These results indicated that if LT rate was to increase in the future, average long-term survival may also increase. However, for some special populations such as the elderly patients, owing to the similar outcomes between LT and LR, the selection of LT should be cautious.
本研究旨在比较I期和II期肝细胞癌（HCC）患者肝移植（LT）和肝切除（LR）的长期预后。
本研究检索了2004年至2015年的SEER 18登记数据。在多变量分析和工具变量（IV）分析中，我们分别纳入了1765例和1746例I-II期（AJCC，第7版）HCC患者。进一步进行倾向评分匹配（PSM）以确保可比性。通过稳定的逆概率治疗加权（IPTW）和标准化死亡率比加权（SMRW）方法调整接受LT的倾向评分。此外，进行IV分析以调整测量和未测量的混杂因素。
我们分别确定了1000例（56.7%）和765例（43.3%）接受LR和LT治疗的患者。在多变量调整队列中，在调整潜在混杂因素后，接受LT的患者在总生存期（OS，P < 0.001）和无病生存期（DSS，P < 0.001）方面比接受LR的患者具有显著的预后优势。本研究中的工具变量是各个医疗服务区（HSA）的LT率。IV分析结果显示，接受LT治疗的病例OS显著更长（P = 0.001），DSS也显著更长（P < 0.001）。在按临床病理变量分层的IV分析中，LT对LR在OS方面的治疗效果在所有亚组中均一致。关于IV分析中的DSS，亚组分析观察到，除老年患者（交互P值 = 0.039）和非白人患者（交互P值 = 0.041）结果相似外，LT在所有亚组中的DSS均更好。在倾向匹配队列中，与接受LR的病例相比，接受LT的患者仍具有更好的OS（P < 0.001）和DSS（P < 0.001）。在IPTW和SMRW队列中，接受LT的患者均具有更好的OS（P值均 < 0.001）和DSS（P值均 < 0.001）。
LT为I-II期HCC患者提供了生存获益。这些结果表明，如果未来LT率增加，平均长期生存率也可能提高。然而，对于一些特殊人群，如老年患者，由于LT和LR的预后相似，LT的选择应谨慎。
