*Purpose: Liver transplant candidates with hepatocellular carcinoma (HCC) risk tumor progression that may disqualify them from transplant eligibility while awaiting HCC exception points on the waitlist. Most centers therefore perform locoregional therapy (LRT) with chemoembolization and/or radiofrequency ablation as a bridge to transplant. Use of LRT to prevent tumor progression and enable eventual transplant is supported by single center studies and consensus guidelines; however, there has been no evaluation of national waitlist outcomes comparing candidates undergoing LRT to those that have not.

*Methods: We used SRTR data to examine adult first time liver transplant candidates with HCC within Milan criteria activated between 1/1/2010 and 5/31/2021 and compared candidates who underwent LRT with to those who did not, stratified by tumor burden at presentation. We used Cox regression models to compare rate of transplant and combined outcome of waitlist mortality and dropout between groups. Models were adjusted for age, race, sex, diagnosis, blood group, insurance, and initial tumor size and type.

*Results: 15796 candidates underwent LRT; 7923 did not. There were no differences between groups in terms of age, sex, or blood group. Candidates receiving LRT were more likely to have a single tumor > 3 cm (26% vs 19%, p<0.001) or multiple tumors (27% vs 23%, p <0.001). There were no differences in transplant rate between groups (Table 1). Candidates undergoing LRT had a lower risk of waitlist mortality/dropout compared to those who did not undergo bridging therapy (Table 2). Stratified by tumor burden, candidates with a single tumor ≤ 3 cm were 11% less likely to die on or drop off the waitlist if they had LRT (95% CI: 0.81-0.89), candidates with a single tumor >3 cm were 21% less likely to die on or drop off the waitlist if they had LRT (95% CI: 0.69-0.90), and there was no difference in waitlist mortality or dropout in candidates with multiple tumors (aHR 0.95; 95% CI 0.83-1.08).

*Conclusions: In this first examination of national SRTR data to examine waitlist outcomes for liver transplant candidates with HCC, we found LRT was associated with decreased waitlist mortality and dropout. Our data suggests the association is largest in candidates with single tumors.

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