Complete necrosis of HCC improves recurrence-free and overall survival after transplantation independent of baseline risk
Zachary T. Berman, Beau B. Toskich, Christopher D. Malone, Kristopher P. Croome, Robert J. Lewandowski, Riad Salem, Maria B. Majella Doyle, Kyril L. Cole, Neil MehtaBackground:
Complete pathologic necrosis (CPN) is associated with improved outcomes after liver transplantation for HCC. Whether this association persists after accounting for hepatic reserve, tumor burden, locoregional therapy modality, and risk of waitlist dropout remains uncertain.
Methods:
We conducted a retrospective cohort study using the Organ Procurement and Transplantation Network Standard Transplant Analysis and Research database, comprising 16,955 adult recipients bridged with locoregional therapy and a comparator group of 5867 recipients with no evidence of pretransplant treatment. Multivariable models were adjusted for hepatic reserve, tumor burden at original presentation, alpha-fetoprotein, and transplant era.
Results:
CPN was achieved in 5,132 patients (30.3%) and was associated with improved survival (adjusted HR: 0.73, 95% CI: 0.68–0.78) and reduced recurrence (adjusted HR: 0.37, 95% CI: 0.31–0.44). Outcomes were similar whether necrosis was absent or incomplete (adjusted HR: 1.39 and 1.37 vs. complete necrosis). Relative to the no treatment comparator, no adjusted survival advantage was detected for treatment without CPN (HR: 0.95, 95% CI: 0.89–1.01), whereas recurrence was higher (HR: 1.44, 95% CI: 1.25–1.66). Compared with transarterial chemoembolization, transarterial radioembolization and percutaneous ablation were associated with higher odds of CPN (adjusted odds ratios 2.19 and 1.84; both
Conclusions:
CPN was strongly associated with reduced posttransplant tumor recurrence and improved overall survival. Radioembolization and thermal ablation were the locoregional therapy modalities most likely to achieve CPN. These findings further establish CPN as an important objective of bridging and downstaging therapy.