Bridging Therapies are not Detrimental in Patients with Hepatocellular Cancer waiting for Liver Transplant: A Propensity Score Analysis
Quirino Lai1,2, Umberto Cillo3, Samuele Iesari1, Armin Finkenstedt4, Massimo Rossi2, Emmanuil Tsochatzis5, Gerd Otto6, Giuseppe M Ettorre7, Giuseppe Tisone8, Marco Vivarelli9, Alfonso W Avolio10, Maxime Foguenne1, Jan Lerut1.
1UCL, Brussels, Belgium; 2Sapienza University of Rome, Rome, Italy; 3University of Padua, Padua, Italy; 4University of Innsbruck, Innsbruck, Austria; 5Royal Free Hospital , London, United Kingdom; 6University of Mainz, Mainz, Germany; 7San Camillo Hospital, Rome, Italy; 8Tor Vergata University, Rome, Italy; 9University of Marche, Ancona, Italy; 10Catholic University of Rome, Rome, Italy
EURHECA-LT.
Patients with hepatocellular cancer (HCC) within Milan Criteria (MC) waiting for liver transplantation (LT) are approached in two different ways: direct LT vs. first treating the tumour using LRT. In these patients, the usefulness of LRT is still questioned.
To investigate the role of LRT in patients with MC-IN HCC waiting for LT in terms of risk of de-listing, intention-to-treat (ITT) survival and post-LT recurrence.
The EurHeCaLT database allowed to identify 1,177 MC-IN HCC patients listed for possible LT. Using propensity score matching, two homogeneous groups of directly transplanted (n=205) vs. firstly LRT treated patients (n=205) were studied.
Median follow-up period was 3.6 years (IQR: 1.5-7.5). Comparing the groups, only two differences were observed, namely a longer median waiting time in the LRT-first group (5vs.4 months; p=0.04) and a greater median dimension of the target lesion at the moment of LT or de-listing in the direct-LT group (2.0vs.1.7 cm; p<0.0001). At multivariate Cox regression analysis, three independent risk factors for ITT-death were identified: MELD (HR=1.04; p=0.005), radiological progression beyond MC (HR=2.04; p=0.03) and alpha-fetoprotein slope >15ng/mL/month (HR=1.75; p=0.03). At multivariate analysis, multimodal LRT approach (HR=3.18; p=0.01) and maximal diameter of the main HCC lesion (HR=1.53; p=0.045) were independent risk factors for post-LT recurrence. Repetitive LRT was not a significant risk factor in both the analyses. Survival over one year in de-listed patients was more common in LRT-first cases (5.9vs.1.0%; p=0.01).
The use of (repetitive) LRT has no detrimental effect in MC-IN patients waiting for LT. LRT represents a tool allowing to further optimize the liver allocation process by selecting patients presenting a high-risk for drop-out (avoiding thereby futile liver transplants). The biological tumor response to the LRT is more than the LRT itself the strongest predictor of intention-to-treat survival and recurrence.
