Liver resection is associated with better survival than TACE for hepatocellular carcinoma modestly beyond Milan criteria: a multicenter propensity-matched analysis

Xiaoyan Fan, Guobin Sun, Yong Meng, Liu Xm, Li Zhang, Yan Peng, Pang Wang, Liping Qiao, Jun Zhu, Rui Chen

Background and aim Liver transplantation (LT) is considered the optimal treatment for hepatocellular carcinoma (HCC) within extended transplant criteria, but it is available to only a minority of patients. The optimal alternative treatment strategy for patients with HCC beyond the Milan criteria (BMC) but still within extended transplant frameworks—defined in this study as modestly beyond the Milan criteria (MBMC)—remains unclear. This study aimed to compare the overall survival (OS) associated with liver resection (LR) versus transarterial chemoembolization (TACE) in patients with MBMC-HCC. Methods Between January 2010 and October 2021, 1,110 patients with MBMC-HCC and Child–Pugh A liver function from 15 hepatobiliary centers in China were included, including 424 who underwent LR and 686 who received TACE. Overall survival was compared between groups using propensity score matching (PSM). The findings were further evaluated in additional BMC-HCC cohorts defined according to other extended transplant criteria, including the Asan criteria, up-to-7 criteria, the French AFP model, and the Metroticket 2.0 model. Results In the multicenter MBMC-HCC cohort, as well as in the additional BMC-HCC cohorts, LR was associated with significantly longer overall survival than TACE (all log-rank P < 0.001). After 1:1 PSM, the survival advantage of LR remained consistent. Multivariable analyses and subgroup analyses across tumor burden and other baseline factors showed similar trends, although these findings should be interpreted with caution. Conclusions LR was associated with significantly better overall survival than TACE in selected patients with MBMC-HCC. These findings support further prospective studies to clarify the role of LR in this population when transplantation is not available.