AT A GLANCE

A new study published in Hepatology reports that patients with hepatocellular carcinoma (HCC) who exceed United Network for Organ Sharing (UNOS) downstaging (DS) criteria may still be candidates for liver transplantation (LT).¹

“Patients with hepatocellular carcinoma (HCC) meeting United Network for Organ Sharing (UNOS)-downstaging (DS) criteria have excellent post-liver transplantation (LT) outcomes,” explain study authors Xu et al. However, “studies on HCC beyond UNOS-DS criteria ("All-Comers" [AC]) have been limited by small sample size[s] and short follow-up time[s], prompting this analysis.”

A total of 326 patients meeting UNOS-DS criteria and 190 patients meeting AC criteria from nine LT centers across five UNOS regions were enrolled from 2015–2023 and prospectively followed. The authors used competing risk and Kaplan-Meier analysis to evaluate DS and LT outcomes, while Fine-and-Gray and Cox models were used to identify predictors of outcomes.

According to the authors, the AC and UNOS-DS participants had similar median alpha-fetoprotein levels (15 vs. 12 ng/mL), Model for End-Stage Liver Disease scores (9 vs. 9 points), and Child–Pugh scores (A vs. A).  

Two years after the first local regional therapy, 82% of UNOS-DS and 66% of AC cases were successfully downstaged. Yttrium-90 achieved greater DS success than transarterial chemoembolization (TACE) in AC (74% vs. 65%), while the converse was true in the UNOS-DS cohort (78.1% vs. 86.5%).

Meanwhile, 48% of UNOS-DS and 40% of AC underwent LT, with 5-year post-LT survival rates being similar between UNOS-DS and AC participants (74% vs. 72%). However, 5-year post-LT recurrence was higher in the AC group (30% vs. 14%). DS rates in AC participants were 72% for sum of tumor number plus diameter of largest lesion <10, 51% for sum 10–12, and 39% for sum >12, respectively.

“Despite higher HCC recurrence and lower intention-to-treat survival in AC, post-LT survival was comparable between UNOS-DS and AC. Yttrium-90 attained higher DS success than transarterial chemoembolization in AC. LT after DS is feasible in AC, though defining an upper limit in tumor burden may be necessary,” conclude the authors.

Reference

1.     Xu E, Tabrizian P, Gutierrez J, et al. Downstaging of hepatocellular carcinoma before liver transplantation: Results from a national multicenter prospective cohort study. Hepatology.2025;82(3):612–625.