Is There a Role for Surgery in T2 and T3 Hepatocellular Carcinoma? A Propensity-matched Analysis of the National Cancer Database

Introduction: The role of hepatectomy for hepatocellular carcinoma (HCC) with multifocality or vascular involvement remains ill-defined. Our objective was to evaluate the potential benefit of surgical resection for patients with these high-risk tumors. Methods: The National Cancer Database was used to identify patients with HCC with vascular involvement and/or multifocal disease (T2 and T3, AJCC Seventh Edition) between 2010 and 2016. Propensity score matching (k nearest neighbors, no replacement, 1:1) was used to create two balanced groups: patients treated with surgical resection and those treated with non-surgical modalities (ablation, radiation including radioembolization, chemotherapy including TACE, or any combination thereof). Groups were matched using patient, clinical, and liver-specific characteristics. Patients undergoing orthotopic liver transplant were excluded. Median overall survival (OS) was calculated using Kaplan-Meier method and adjusted analyses were performed using Cox proportional hazards models. Results: A total of 24,488 patients met inclusion criteria, including 2,231 (9.1%) treated with surgical resection. Median OS for the cohort was 17.7 months. Following propensity matching, surgical resection was associated with a survival advantage (36.7 months) compared to non-surgical treatment (19.9 months, log-rank P< .001, Figure). Adjusted analysis demonstrated an OS advantage of surgery versus non-surgical treatments in both unmatched (adjusted hazard ratio, 0.58, 95% confidence interval, 0.54 - 0.62) and matched groups (adjusted hazard ratio, 0.55, 95% confidence interval, 0.51 - 0.60). Conclusion: Surgical resection is associated with a survival advantage in HCC with multifocal disease and/or vascular involvement. The presence of these features should not contraindicate consideration of hepatectomy in suitable candidates.