Resection vs Transplant Listing for Hepatocellular Carcinoma: An Intention-to-Treat Analysis Guy Meyerovich a , Yaacov Goykhman a , Richard Nakache a , Ido Nachmany a , Guy Lahat a , Oren Shibolet b , Yoram Menachem b , Helena Katchman b , Ido Wolf c , Ravit Geva c , Joseph M. Klausner a , and Nir Lubezky a, * a Department of Surgery, Tel Aviv Medical Center, Tel Aviv, Israel; b Institute of Gastroenterology, Tel Aviv Medical Center, Tel Aviv, Israel; and c Institute of Oncology, Tel Aviv Medical Center, Tel Aviv, Israel ABSTRACT Background. Liver transplantation (LT) and liver resection (LR) are curative treatment options for patients with hepatocellular carcinoma within the Milan criteria. Severe organ shortage dictates the preference for LR. Our aim was to provide an intention-to-treat retrospective comparison of survival between patients who were placed on waiting lists for LT and those who underwent LR. Methods. The medical records of patients with hepatocellular carcinoma within the Milan criteria treated by LR or listed for LT between 2007 and 2016 were reviewed. We performed intention-to-treat analyses of overall survival and recurrence. Results. There were 54 patients on the waiting list for LT, and 30 of them underwent LR. Thirteen of the 54 patients (24%) were not transplanted because of disease-related mortality or tumor progression. The median waiting time to transplantation was 304 days. The 90-day mortality was higher in transplanted patients (9.8% vs 3.3%, P ¼ .003). Intention-to-treat survival was similar for the LT and LR groups (5-year survival, 47.8% vs 55%, respectively, P ¼ .185). There was a trend toward improved 5-year disease-free survival for listed patients (56.2% vs 26.3% for patients undergoing LR, P ¼ .15). Conclusion. Intention-to-treat survival is similar in patients undergoing LR and those on waiting lists for LT. There is a 24% risk to drop from the transplant list. The higher perioperative mortality among patients undergoing LT is balanced by a higher tumor recurrence rate after LR H EPATOCELLULAR carcinoma (HCC) is the most common primary liver malignancy and one of the 3 most common causes of cancer-related deaths worldwide [1,2]. HCC mostly develops in patients with chronic liver disease. Curative therapeutic options for patients with early HCC include liver resection (LR) and orthotopic liver transplantation (LT). LR can be performed with low peri- operative morbidity and mortality in selected patients with chronic liver disease who have preserved liver function and no signs of clinically significant portal hypertension [3e5]. However, intrahepatic recurrence rates related to both intrahepatic metastases from the primary tumor and new primary cancers developing in the diseased carcinogenic liver are high, and they negatively impact long-term onco- logic results [6e9]. LT is a therapeutic option that is available for patients with advanced liver disease and early HCC within the Milan criteria (MC). Advantages of LT over LR include the elimination of intrahepatic metastasis and of the risk for developing HCC in the carcinogenic parenchyma, thus leading to reduced tumor recurrence rates [10e13]. How- ever, severe organ shortage leads to prolonged waiting times, during which patients may develop tumor progression and be dropped from the transplant list. Additionally, perioperative morbidity and mortality are higher after LT *Address correspondence to Nir Lubezky, MD, Liver Surgery Unit, Department of Surgery, Tel Aviv Medical Center, 6 Weizman St, Tel Aviv 6423906, Israel. E-mail: nirl@tlvmc.gov.il ª 2019 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169 0041-1345/19 https://doi.org/10.1016/j.transproceed.2019.02.030 Transplantation Proceedings, 51, 1867e1873 (2019) 1867