*Purpose: Yttrium-90 microspheres radioembolization (Y90) has shown to be effective as a bridging therapy for patients with advanced hepatocellular carcinoma (HCC) while on waiting list for liver transplantation (LT). However, the association between explant pathology after Y90 and post-transplant recurrence of HCC has not been well investigated. The aim of this study is to evaluate the association between explant pathology and recurrence of HCC in patients who underwent Y90.

*Methods: From 2013 to 2019, 147 patients who received LT for HCC at a single center were evaluated. Eight patients didn’t receive bridging therapy and were excluded from this study. 139 patients were divided into those in which Y90 was included in their locoregional treatment (LRT), with or without the addition of TACE, RFA, and resection (Group A, n=27), and LRTs without Y90 (Group B, n=112). Tumor characteristics pretransplant and in explant liver and cumulative incidence of HCC recurrence after LT were compared between 2 groups.

*Results: Group A had significantly higher AFP at listing than Group B (13.2 ng/ml vs 7.3 ng/ml, p=0.01) and at maximal level (16.2 ng/ml vs 9.4 ng/ml, p=0.02). AFP level at the time of LT was relatively higher in Group A compared to Group B, but the difference was not significant (16.2 ng/ml vs 9.4 ng/ml, p=0.06). The proportion of patients who exceeded Milan criteria by explanted liver (22.2% vs 27.7%, p=0.64) and who achieved complete pathological response (cPR) in explanted liver was similar (40.7% vs 25.2%, p=0.15). However, Group A showed significantly higher cumulative incidence of recurrence compared to Group B (p=0.009). Of note, post-transplant recurrence was found in 5 (18.5%) patients in Group A, 4 of whom had viable HCC lesions. In Group A, patients without cPR showed a trend toward higher recurrence compared to those with cPR, but it did not reach statistical significance (p=0.39, Figure B).

*Conclusions: Patients who underwent Y90 showed higher incidence rate of HCC recurrence, which may be attributable to residual viable HCC or advanced tumor pathology. It is critical to eradicate HCCs before LT to achieve lower recurrence rate especially in patients who underwent Y90.

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