Postinterventional tumor necrosis predicts recurrence-free long-term survival in liver transplant patients with advanced hepatocellular carcinoma

Background: Locoregional interventional bridging treatment (IBT) before liver transplantation (LT) is an accepted neoadjuvant approach in liver transplant patients with hepatocellular carcinoma (HCC). However, the effect of postinterventional tumor necrosis on posttransplantation outcome is known. Methods: A total of 93 consecutive liver transplant patients with HCC were included in this prospective trial. Fifty-nine patients underwent pretransplantation IBT, by either transarterial chemoembolization (n = 51) or radiofrequency ablation (n = 8). The extent of tumor necrosis assessed at explant pathology (≥50% tumor necrosis rate = extended post-IBT tumor necrosis; <50% tumor necrosis rate = less extended tumor necrosis) and its impact on recurrence-free survival in the context of other prognostic relevant histopathologic variables were analyzed in uni- and multivariate analyses. Results: Extended tumor necrosis was assessed in 44 patients among the IBT population, and tumor necrosis rate was <50% in 15 patients of the IBT and 34 patients of the non-IBT population, respectively. Five-year recurrence-free survival rates were 96% in patients with and 55% in patients without extended tumor necrosis rates (P <.001). Recurrence-free survival rates were similar between patients with HCC meeting the Milan criteria (85%) and those exceeding the Milan criteria but demonstrating extended post-IBT tumor necrosis on explant pathology (80%). On multivariate analysis, only microvascular invasion (odds ratio 6.4) and extended postinterventional tumor necrosis (odds ratio 9.2) were identified as independent histopathologic predictors of recurrence-free outcome (P <.05). Conclusions: Extended tumor necrosis should be the major objective of neoadjuvant IBT in liver transplant patients with HCC, because it significantly improves posttransplantation outcome. Thereby, even patients with HCC beyond the Milan criteria may achieve excellent survival rates.