title: An analysis of resection vs transplantation for early hepatocellular carcinoma: defining the optimal therapy at a single institution.
abstract: BACKGROUND
  The reported survival after liver transplantation (OLT) for early hepatocellular carcinoma (HCC) is superior to the results of liver resection (LR), but few analyses have considered long waiting times and patient drop-offs due to tumor progression.
  
  
  METHODS
  From 1995-2005, 347 patients with HCC were evaluated at our institution and underwent either LR (n = 174) or placed on the OLT waiting list (n = 173). Patients who only underwent ablation were not included. After eliminating patients with 1) incidental tumors after OLT, 2) tumors outside of Milan criteria, 3) preoperative vascular invasion prior to LR and 4) Child-Pugh Class C cirrhosis prior to OLT, 261 patients (LR = 121; OLT = 140) were included in this analysis.
  
  
  RESULTS
  Median follow-up time was 35 months. Median waiting time for OLT was 7.7 months; during this time, 30 patients were taken off the waiting list. Overall survival (OS) from time of listing or LR was not different between the two groups; 1, 3, and 5 year OS after LR was 89%, 75%, and 56% compared with 90%, 70%, and 64% for OLT (P = .84). Only patients who waited <4 months for OLT (n = 67) had better survival than those who underwent LR (P = .05). Patients who waited longer that four months for OLT had a 2.5x higher risk of death in a Cox multivariate model [odds ratio (OR) 2.5; 95% confidence interval (CI): 1.3-5; P = .007].
  
  
  CONCLUSIONS
  Unless waiting time is short (< 4 months), the survival of patients with early HCC is similar between LR and LT.
authors.affiliation: Department of Surgery, University Health Network, University of Toronto, Toronto, Canada. shahs01@ummhc.org
authors.forename: Shimul A
authors.initials: SA
authors.lastname: Shah
authors.forename: Sean P
authors.initials: SP
authors.lastname: Cleary
authors.forename: Jensen C C
authors.initials: JC
authors.lastname: Tan
authors.forename: Alice C
authors.initials: AC
authors.lastname: Wei
authors.forename: Steve
authors.initials: S
authors.lastname: Gallinger
authors.forename: David R
authors.initials: DR
authors.lastname: Grant
authors.forename: Paul D
authors.initials: PD
authors.lastname: Greig
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000601:surgery*; D016009:Chi-Square Distribution; D018450:Disease Progression; D005260:Female; D006801:Humans; D008113:Liver Neoplasms / Q000601:surgery*; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D015996:Survival Rate; D016896:Treatment Outcome; D014850:Waiting Lists