Localized hepatocellular carcinoma: Is liver-directed therapy alone as efficacious as surgical resection?

Studies of the efficacy of nonsurgical methods of liver-directed therapy (percutaneous microwave or radiofrequency ablation, transarterial bland embolization, chemoembolization, and/or radioembolization) in the treatment of hepatocellular cancer lack contemporaneous comparative surgical cohorts. The role of these methods of liver-directed therapy as destination treatment in hepatocellular cancer is not well defined. We queried our institutional registry for patients undergoing resection or liver-directed therapy alone for clinical stage I to IVa hepatocellular cancer between 2012 and 2022. Multivariable regression and Cox modeling were used to identify factors associated with resection and all-cause mortality. Patients undergoing resection were 1:3 propensity matched for age, Mayo End-Stage Liver Disease score and clinical stage to those undergoing liver-directed therapy. Kaplan-Meier methods were used to compare 5-year disease-specific and overall survival for matched cohorts. Three hundred thirty patients met inclusion criteria; 45 underwent resection, and 285 liver-directed therapy. On multivariable regression, factors associated with resection included age (adjusted odds ratio: 0.96, P = .007) and Mayo End-Stage Liver Disease score (adjusted odds ratio: 0.92, P = .033). On Cox modeling, factors associated with mortality-risk included Mayo End-Stage Liver Disease score (adjusted hazards ratio: 1.03, P = .01), advanced clinical stage (stage III adjusted hazards ratio: 1.9, P = .002), and resection (adjusted hazards ratio: 0.43, P = .001). Forty-five patients undergoing resection were matched to 135 undergoing liver-directed therapy. On Kaplan-Meier comparison of matched cohorts, patients undergoing resection demonstrated improved overall survival (38.1 vs 8.4%, P = .015) but disease-specific survival similar to that for those undergoing liver-directed therapy (84.0 vs 74.0%, P = .095). Liver-directed therapy is effective as treatment for patients with localized hepatocellular cancer providing disease-specific survival similar to that provided by surgical resection.