Objective: OPTN has recently approved MELD prioritization for HCC patients beyond Milan Criteria (MC) who are downstaged (DS) with locoregional therapy (LRT) prior to liver transplant (LT). We sought to evaluate post-LT outcomes, identify predictors of downstaging, and evaluate the impact of LRT in HCC patients presenting beyond MC.

Methods: Clinicopathologic characteristics and outcomes were compared among beyond MC patients (n=789) who were downstaged (DS, n=465), treated and not downstaged (LRT-NoDS, n=242), or untreated and not downstaged (NoLRT-NoDS, n=82) from 20 US centers (2002-2013). Logistic regression identified predictors of downstaging. Among non-downstaged patients, multivariate Cox regression and propensity matching with inverse probability of treatment weighted analysis determined the effect of LRT on HCC recurrence.

Results: Compared to NoDS, recurrence-free survival was superior and post-LT recurrence lower in DS, with further stratification of risk by tumor > 5cm. Multivariate predictors of downstaging included pre-LT AFP response, and pathologic tumor number and size. Surprisingly, LRT-NoDS had higher recurrence rates compared to NoLRT-NoDS, even after controlling for clinicopathologic variables (HR 2.43[1.47-4.00], p=0.001) and propensity matching (HR 2.60[1.58-4.28],p<0.001).

Conclusions: Downstaging beyond MC patients results in excellent post-LT outcomes, particularly if maximum radiologic tumor diameter is < 5 cm, and is predicted by pre-LT AFP response but not LRT number or modality. In treated non-downstaged patients, the significantly higher recurrence compared to non-treated non-DS patients cannot be explained by measured clinicopathologic differences, and suggests a potentially aggravating role for LRT on post-LT recurrence in these patients who display poor tumor biology.

CITATION INFORMATION: Agopian V., United States Multicenter HCC Transplant Consortium Liver Transplantation for Patients with Hepatocellular Carcinoma Presenting beyond Milan Criteria: Analysis of 789 Patients from the US Multicenter HCC Transplant Consortium Am J Transplant. 2017;17 (suppl 3).

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