TKIs treatment for HCC before Liver transplantation: an ELITA/ELTR collaborative study

Background and Aims
Recent advances in systemic treatments for hepatocellular carcinoma (HCC) have driven the discussion on 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. The aim of this study was to evaluate the outcome of patients treated with TKIs before LT.

Method
an online survey was sent to all centers affiliated to the ELITA/ELTR network between June and December 2022. Demographic and clinical data were retrospectively collected.

Results
Fifty-two patients, median age 60.5 years, receiving a LT between December 2006 and September 2022 were enrolled. Thirty patients (57.6%) were treated with TKI with a downstaging purpose, while 22 (42.3%) received TKI as a bridging treatment to LT. 34 patients (65%) received sorafenib, 15 lenvatinib (28%) and 3 patients (3%) a sequential therapy with sorafenib-regorafenib. Forty-eight patients (92%) received at least one locoregional treatment before LT. Only 12 patients (23%) were in Milan criteria at treatment start time. Twenty-nine patients were Milan-in at listing (55.7%). Nine patients had neoplastic portal vein thrombosis (17.3%). The five-year survival was 70% (Figure 1). After a median time of 7.7 months (5-12.7), 7 patients (13%) experienced HCC recurrence. The only factor associated with HCC recurrence was AFP (p 0.02) at LT-We observed only a single recurrence in one of the patients with neoplastic thrombosis. Twelve patients (23%) experienced vascular or early bleeding complications after LT. The type of TKIs or the time from the last dose to LT didn't influence the risk of post-LT complications.

Conclusions
This is the largest collected series of patients receiving TKIs pre-LT as downstaging/bridging therapy, with a very favourable long-term outcome (70 % at 5 years) even in patients with neoplastic vein thrombosis.