TKI treatments for HCC before liver transplantation: a collaborative European study

Background and Aims: Recent advances in systemic treatments for hepatocellular carcinoma (HCC) have prompted the discussion regarding their possible role for downstaging advanced HCC prior to liver transplantation (LT) or for bridging to LT to prevent tumor progression and reduce the dropout risk.
Method: Data of patients with HCC treated with different TKI before LT were collected using an online Survey in 16 different centres across Europe.
Results: 48 patients with a mean age of 60 years and receiving a LT between December 2006 and September 2022 were enrolled. 26 patients were treated with TKI with a downstaging purpose, while 22 received TKI as a bridging treatment to LT. 34 patients (71%) received sorafenib, 13 lenvatinib (27%) and 1 patient (2%) a sequential therapy with sorafenib-regorafenib. 41 patients (85%) received at least one locoregional treatment before LT. 27 patients were Milan-in at listing (56%). After a median follow up of 464 days (20-3005), 6 patients (12.5%) experienced recurrence of HCC after LT (3 patients were Milan-in and 3 Milan out at listing). We observed 4 cases of early mild-moderate graft rejection (8%) and 8 (16%) cases of vascular complications (artery thrombosis or arterial bleeding) early after LT. All vascular complications occurred in the group of patients treated with TKI as downstaging treatment, with last administration of TKI 158 days before LT.
Conclusion: This is largest series of patients receiving TKI pre-LT reported to date which confirms very favorable short-term outcome (93% one-year overall survival).