*Purpose: Radiofrequency ablation (RFA) is a safe and effective treatment for patients with limited hepatocellular carcinoma (HCC). Ablative outcomes have been largely based on radiological response, and confirmatory data based on histological review are limited. The aim of this study is to correlate the radiological tumor response of RFA with the histopathologic examination of explanted livers following liver transplantation (LT).

*Methods: All compensated patients treated with RFA prior to LT at our institution from 2007-2018 were included in this study. Clinical, pathological explant evaluation and survival outcomes were collected from our prospectively collected database.

*Results: 29 patients were treated with RFA prior to LT. Mean age was 58 years (range 21-75). The average time between RFA and LT was 8 months (range 1-24). The etiology of liver disease was as follows: HCV 13 (44.8%), HBV 9 (31%), Non-alcoholic steatohepatitis 5 (17.2%) and progressive familial intrahepatic cholestasis 2 (7%). 12(41%), 12 (41%), and 5 (18%) of patients had a single, two, or three lesions, respectively. 17 (58.6 %), 8 (27.6%), 3 (10.3%), and 1 (3.4%) received 1, 2, 3, and 4 sessions, respectively. Average pretreatment alfa fetoprotein was 139 (range 3.5-2159). When comparing RFA for single or multiple HCC with no lesion more than 3 cm pathological cure was significantly higher, 85% (12/14) of cases vs 46% (7/15) in patients with lesions exceeding 3 cm (p value=0.027). Pathological cure was 100% (4/4) in patients with a single lesion less than 3 cm. Furthermore, 6 patients had lesions on the explant examination that was not demonstrated on the pretransplant imaging, of them 5 patients had multifocal HCC while the remaining patient had a 4.2 cm lesion prior to RFA. Two patients developed new lesions on follow up imaging prior to LT. None of the included patients developed post-transplant HCC recurrence during the post-LT follow up period (54 months, range 1-131 months) and the overall survival was 76%.

*Conclusions: The HCC histopathologic characteristics in the explanted liver at the time of LT has a dual function in both reflecting the efficacy of preoperative locoregional therapy and as a predictive factor for HCC recurrence. Our data suggests that RFA can afford HCC patients excellent short-term tumor control even when their cancer is multifocal in nature, provided that the largest tumor is < 3 cm. This study also provides further evidence that modern imaging is still fallible in demonstrating active HCC especially in those with multifocal tumors prior to RFA.

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