Introduction We examined the survival of patients transplanted for progressive hepatocellular cancer (HCC) not controlled with locoregional therapy (LRT) and the impact of the strategy to use marginal quality (MQ) liver allografts for these urgent patients. Methods 283 patients were transplanted for HCC at a single center (3/2002-2010); 168 patients had serial imaging to determine HCC progression. Urgency was defined by pre-transplant radiographic disease progression [uncontrolled (U)] vs. controlled (C)]. A subset analysis was done on 83 recipients with complete data on donor quality and recipient clinical variables to assess donor risk index (DRI) (Table). MQ grafts were considered to have DRI>1.8. Results 73% of patients received LRT (90% chemoembolization), and tumor progression was observed in 48%. Uncontrolled patients had more advanced explant pathology [Outside Milan: 38% (U) vs. 8% (C)], lower survival (63.1% vs 76.4% at 5 years) and increased recurrence (16.3% vs 5.9%). MQ grafts diminished wait time [8.8months vs. >16.8m] and were associated with good long term survival in controlled HCC but only 35% 5-year survival in uncontrolled HCC. Conclusion HCC that is not able to be controlled with pre-transplant LRT has poorer outcome. The use of marginal quality livers in HCC patients decreases waiting time and provides good outcome in controlled HCC, whereas expeditious transplantation of uncontrolled HCC with MQ allografts is associated with worse long-term outcomes, most likely due to tumor burden and biology.

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