# Laparoscopic Microwave Ablation and Salvage Liver Transplantation in Patients with Hepatocellular Carcinoma

## TL;DR

This study explores combining laparoscopic microwave ablation with liver transplantation for hepatocellular carcinoma, showing a 62% five-year survival rate.

## Contribution

The first assessment of laparoscopic microwave ablation as part of a salvage liver transplantation strategy for hepatocellular carcinoma.

## Key findings

- A 62% five-year overall survival rate was observed in patients using the combined L-MWA and SLT approach.
- Older age, non-HBV causes, and elevated AFP levels predicted treatment failure.
- Successful treatment led to a 79% five-year survival rate, compared to 22% in failure cases.

## Abstract

This study investigates the effectiveness of a combined strategy involving laparoscopic microwave ablation (L-MWA) as a first-line curative treatment for hepatocellular carcinoma (HCC) and salvage liver transplantation (SLT) in cases of HCC recurrence. Given the limited availability of donor organs, the demand for effective alternatives is increasing. While L-MWA has shown promising results in treating small tumours, this research is the first to assess the feasibility and efficacy of incorporating L-MWA into a “salvage liver transplantation” approach. Beyond evaluating patient outcomes, the study aims to identify predictors of survival and treatment failure. The findings could improve the management of HCC by optimising the use of scarce organ resources and enhancing the transplant benefit for the population.

Background/Objectives: Salvage liver transplantation (SLT) is a well-established option for hepatocellular carcinoma (HCC) recurrence after liver resection. Laparoscopic microwave ablation (L-MWA) represents another curative strategy for early-stage HCC. However, its role within this therapeutic framework remains unexplored. Methods: Between 2014 and 2023, we treated 1341 patients with HCC using L-MWA. From this cohort, patients with Child-Pugh class A liver function, HCC within the Milan criteria, no contraindications to transplantation, and ≥12 months of follow-up were selected. SLT failure was defined as non-transplantable recurrence or death, resulting in the loss of a potentially curative therapeutic opportunity. The primary endpoint was overall survival (OS); secondary endpoints included predictors of survival and SLT failure. Results: A total of 341 patients met the inclusion criteria. Five-year OS was 62%. Independent predictors of poorer survival included the presence of cardiac disease or oesophageal varices, a Child-Pugh score of 6, tumour size, and elevated alpha-fetoprotein (AFP) levels. Treatment was successful in 255 patients (74.8%): 102 (29.9%) underwent SLT, 67 (19.6%) received alternative therapies, and 93 (27.3%) remained recurrence-free. Treatment failure occurred in 86 patients (25.2%) due to non-transplantable recurrence or death. Independent predictors of failure included older age, non-HBV aetiology, and elevated AFP levels. Five-year OS rates were 79% in the success group and 22% in the failure group (p < 0.001). Conclusions: A combined L-MWA and SLT strategy is safe and effective, yielding a 62% 5-year OS rate. This approach supports more efficient graft use with a consequent increase in the population transplant benefit. Improved selection may further reduce failure rates.