Post-recurrence Survival After Liver Transplantation for Hepatocellular Carcinoma

Background. Mortality after liver transplantation (LT) for hepatocellular carcinoma (HCC) is mainly driven by HCC recurrence. We sought to determine whether post-recurrence survival (PRS) has improved during the last 2 decades. Methods. Using the Scientific Registry of Transplant Recipients, we included all patients who underwent LT for HCC between 2003 and 2020 and experienced HCC recurrence. Patients were divided into 4 eras (2003–2007, 2008–2012, 2013–2016, and 2017–2020) according to their year of recurrence. Results. Of 26 309 patients who underwent LT for HCC, 2518 patients were included: 276 (11%) in era 1; 662 (26.3%) in era 2; 685 (27.2%) in era 3; and 895 (35.5%) in era 4. Patients in later eras were more likely to be outside Milan, but within Metroticket 2.0, and underwent more bridging therapies. Median PRS was 9 mo (95% confidence interval [CI], 8-10 mo) for era 1, 13 (11-15) for era 2, 15 (13.5-16.5) for era 3, and 17 mo (15-19 mo) for era 4 ( P < 0.001). After adjusting for time to recurrence, only the comparison between era 1 and era 4 remained significant. At multivariable analysis, only time to recurrence <24 mo (hazard ratio, 1.4; 95% CI, 1.2-1.7; P < 0.0001) and poorly differentiated HCC (hazard ratio, 1.5; 95% CI, 1.2-1.8; P < 0.0001) were associated with PRS, while recurrence era was not. Conclusions. PRS has only modestly improved during the last 2 decades. Despite more patients undergoing bridging therapies in later eras, PRS has not changed compared with eras with more restrictive transplant criteria.