Tumor biology and pre‐transplant locoregional treatments determine outcomes in patients with T3 hepatocellular carcinoma undergoing liver transplantation

Liver transplantation is the optimal treatment for patients with hepatocellular carcinoma ( HCC ) and cirrhosis. This study was conducted to determine the impact of pre‐transplant locoregional therapy ( LRT ) on HCC and our institution's experience with expansion to U nited N etwork of O rgan S haring R egion 4 T 3 ( R 4 T 3) criteria. Two hundred and twenty‐five patients with HCC (176 meeting M ilan and 49 meeting R 4 T 3 criteria) underwent liver transplantation from 2002 to 2008. Compared with the M ilan criteria, HCC s in R 4 T 3 criteria displayed less favorable biological features such as higher median alpha‐fetoprotein level (21.9 vs. 8.5 ng/mL, p = 0.01), larger tumor size, larger tumor number, and higher incidence of microvascular invasion (22% vs. 5%, p = 0.002). As a result, patients meeting M ilan criteria had better five‐yr survival (79% vs. 69%, p = 0.03) and a trend toward lower HCC recurrence rates (5% vs. 13%, p = 0.05). Pre‐transplant LRT did not affect post‐transplant outcomes in patients meeting M ilan criteria but did result in lower three‐yr HCC recurrence (7% vs. 75%, p < 0.001) and better three‐yr survival (p = 0.02) in patients meeting R 4 T 3 criteria. Tumor biology and pre‐transplant LRT are important factors that determine the post‐transplant outcomes in patients with HCC who meet R 4 T 3 criteria.