# The Impact of Local Ablative Therapies as Bridging Treatment on Overall Survival Following Liver Transplantation in Patients with HCC

## TL;DR

This study shows that using local ablation therapies before liver transplants improves survival in hepatocellular carcinoma patients, with different treatments working best depending on tumor burden.

## Contribution

The study identifies that SIRT and TACE have distinct survival benefits based on tumor burden and transplant criteria.

## Key findings

- Neoadjuvant therapy is associated with improved overall survival after liver transplantation for HCC.
- TACE is more effective for patients within transplant criteria with lower tumor burden.
- SIRT provides better outcomes for patients with higher tumor burden or those beyond standard criteria.

## Abstract

The use of neoadjuvant therapies in patients with hepatocellular carcinoma prior to liver transplantation has gained increasing relevance in recent years, yet evidence regarding their impact on post-transplant outcomes remains limited. This study aimed to assess the effect of neoadjuvant therapies on overall survival following liver transplantation in patients with hepatocellular carcinoma and to compare outcomes across treatment modalities with respect to tumor burden. A total of 107 patients were analyzed, including 90 who underwent neoadjuvant treatment. Therapeutic strategies comprised SIRT, TACE, liver resection, and combined SIRT/TACE. Neoadjuvant therapy was associated with a significant survival benefit after liver transplantation. TACE demonstrated the greatest efficacy in patients meeting established transplant criteria, typically characterized by lower tumor burden, whereas SIRT conferred superior benefit in patients with higher tumor burden or those beyond conventional listing criteria.

Background: The use of neoadjuvant therapies in patients with hepatocellular carcinoma prior to liver transplantation has gained increasing popularity in recent years. To date, there are only limited data investigating the impact of neoadjuvant therapy on post-transplant survival. Methods: In this retrospective study, we evaluated patients with hepatocellular carcinoma who underwent deceased donor or living donor liver transplantation at Jena University Hospital between 2019 and 2023. Comprehensive clinical and pathological variables were systematically analyzed, including correlations between neoadjuvant therapy use, tumor burden and overall survival. Survival outcomes were estimated using the Kaplan–Meier method. Results: A total of 107 patients were included in the analysis, of whom 90 received neoadjuvant therapy prior to transplantation. Treatment modalities comprised SIRT, TACE, liver resection and combined SIRT and TACE. The 1-, 3-, and 5-year OS rates following transplantation were 93.5%, 82.2%, and 79.4%, respectively. Recurrence-free survival at 1, 3, and 5 years was 91.6%, 85.0%, and 83.2%, respectively. Among the various neoadjuvant strategies, SIRT and TACE yielded the highest OS rates. Patients listed outside the transplantation criteria (Milan, UCSF, up-to-seven) at the time of initial diagnosis who underwent SIRT had significantly better OS than those outside the criteria who underwent TACE. In contrast, among patients within the Milan, UCSF and up-to-seven criteria, TACE was associated with superior OS compared with SIRT. Conclusion: The use of neoadjuvant therapies confers a significant survival benefit following liver transplantation in patients with HCC. TACE appears to be most suitable for patients listed within established transplantation criteria, who consequently have a lower tumor burden. In contrast, SIRT is more beneficial for patients with a higher tumor burden and those beyond standard transplantation criteria. A limitation of our study, however, is that the included SIRT cohort comprised only 24 patients, and TACE was preferentially performed in patients with a lower tumor burden, which means that a selection bias cannot be fully excluded. Overall, further studies are required to define the optimal bridging strategies.