title: Survival Benefit of Liver Transplantation Versus Resection for Hepatocellular Carcinoma: Impact of MELD Score.
abstract: BACKGROUND
  We sought to measure the impact of model for end stage liver disease (MELD) score, tumor staging, and microvascular invasion (MVI) on the relative survival benefit of liver transplantation (LT) versus liver resection (LR) for hepatocellular carcinoma (HCC).
  
  
  METHODS
  The study population comprised 1,106 HCC patients with cirrhosis undergoing LR from one Eastern (n = 424) and two Western (n = 682) surgical units. Exclusion criteria were very large (>10 cm) tumors, macrovascular invasion, and metastases. We identified three tumor stages: stage I (within Milan, n = 806), stage II (beyond Milan within Up-to-7, n = 123), and stage III (beyond Milan and Up-to-7, n = 177). Patient survival after LR was compared to that predicted after LT by the Metroticket calculator in relationship with staging, MVI, and MELD score using Monte Carlo simulation.
  
  
  RESULTS
  Two hundred eighty-three patients (26 %) with a MELD score of ≥10 had an acceptable 5-year survival after LR of 47 %, while that of patients with a low MELD score was 67 % (p < 0.0001). Mean 5-year LT benefit was -4.50 months (95 % confidence interval [CI] -4.73 to -4.27) for patients with a MELD score of <10, and 0.81 months (95 % CI 0.58 to 1.04) for those with a MELD score of ≥10. MELD score and MVI were the strongest predictors of transplant survival benefit. LT reached a survival benefit, versus LR only in HCC patients with a MELD score of ≥10 and without MVI (3.08 months, 95 % CI 2.78 to 3.39), whatever the tumor stage.
  
  
  CONCLUSIONS
  LT proved to be harmful in patients with resectable HCC with a low MELD score (<10) or with aggressive tumors (with MVI). As a result of a shortage of donors, only selected resectable tumors with a MELD score of ≥10 should be considered for transplantation.
authors.affiliation: Hepatobiliary Surgery and Liver Transplantation Unit, Department of General Surgery and Organ Transplantation, University Hospital of Padua, Padua, Italy, alessandro.vitale@unipd.it.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Vitale
authors.forename: Teh-la
authors.initials: TL
authors.lastname: Huo
authors.forename: Alessandro
authors.initials: A
authors.lastname: Cucchetti
authors.forename: Yun-Hsuan
authors.initials: YH
authors.lastname: Lee
authors.forename: Michael
authors.initials: M
authors.lastname: Volk
authors.forename: Anna Chiara
authors.initials: AC
authors.lastname: Frigo
authors.forename: Matteo
authors.initials: M
authors.lastname: Cescon
authors.forename: Francesco
authors.initials: F
authors.lastname: Tuci
authors.forename: Antonio Daniele
authors.initials: AD
authors.lastname: Pinna
authors.forename: Umberto
authors.initials: U
authors.lastname: Cillo
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D006528:Carcinoma, Hepatocellular / Q000401:mortality* / Q000473:pathology / Q000601:surgery; D002648:Child; D005260:Female; D005500:Follow-Up Studies; D006498:Hepatectomy / Q000401:mortality*; D006801:Humans; D008113:Liver Neoplasms / Q000401:mortality* / Q000473:pathology / Q000601:surgery; D016031:Liver Transplantation / Q000401:mortality*; D008297:Male; D008875:Middle Aged; D009010:Monte Carlo Method; D009361:Neoplasm Invasiveness; D009367:Neoplasm Staging; D011379:Prognosis; D011446:Prospective Studies; D012307:Risk Factors; D015996:Survival Rate; D055815:Young Adult