We retrospectively analyzed our long term experience on the use of PBRT versus TACE for downstaging or bridge therapy of HCC prior to LT. Methods: Patients received either PBRT or TACE as determined by a multidisciplinary HCC treatment team. PBRT was administered (63 Gy delivered in 4.2 Gy daily fractions, 15 fractions over 3 wks) after obtaining treatment-planning CT scans; TACE was doxorubicin-based with conventional lipiodol prior to 2009 and then with drug-eluting beads. CT or MRI was obtained 1 month post treatment then every 3 months until LT. Post LT, imaging was performed up to 5 years for recurrence surveillance. Patients had MELD HCC upgrades per UNOS policy; some of the patients were listed after downstaging to Milan criteria according to Region 5 policy. Results: Of 437 patients transplanted at our center, 82 (19%) patients had HCC. 8 patients did not have any pre LT treatment and 2 patients had RFA. 28 patients were treated with PBRT and 40 patients with TACE; 3 patients had PBRT after TACE and 1 patient had TACE after PBRT due to inadequate treatment response. Time from diagnosis of HCC to LT in the PBRT and TACE groups was 14.5 ± 13 and 16.5 ± 10 months (p=0.5), and mean transplant MELD was 33 ± 4 and 32 ± 5 (p=0.3), respectively, consistent with the long wait times in our region. There were significantly more patients with pathologic staging both within and outside Milan criteria in the TACE group, while more patients had no identifiable tumor in the PBRT cohort (Table). HCC recurrence occurred in 1 patient in the PBRT group (died 13 months post LT) and in 2 patients in the TACE cohort (1 died 14 months post LT and another patient is still alive with adrenal metastases 23 months post LT). One- and 5-year patient survival was similar between both groups (PBRT, 89% and 66%; TACE, 90% and 69%, respectively) (p=0.29) as was graft survival (not shown). Summary: PBRT is an excellent modality for the management of HCC prior to LT.

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