Liver Transplantation Following Yttrium‐90 Radioembolization: 15‐Year Experience in 207‐Patient Cohort

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Abstract
Background and Aims: Radioembolization (yttrium‐90 [Y90]) is used in hepatocellular carcinoma (HCC) as a bridging as well as downstaging liver‐directed therapy to curative liver transplantation (LT). In this study, we report long‐term outcomes of LT for patients with HCC who were bridged/downstaged by Y90. Approach and Results: Patients undergoing LT following Y90 between 2004 and 2018 were included, with staging by United Network for Organ Sharing (UNOS) tumor‐node‐metastasis criteria at baseline pre‐Y90 and pre‐LT. Post‐Y90 toxicities were recorded. Histopathological data of HCC at explant were recorded. Long‐term outcomes, including overall survival (OS), recurrence‐free survival (RFS), disease‐specific mortality (DSM), and time‐to‐recurrence, were reported. Time‐to‐endpoint analyses were estimated using Kaplan–Meier. Univariate and multivariate analyses were performed using a log‐rank test and Cox proportional‐hazards model, respectively. During the 15‐year period, 207 patients underwent LT after Y90. OS from LT was 12.5 years, with a median time to LT of 7.5 months [interquartile range, 4.4‐10.3]. A total of 169 patients were bridged, whereas 38 were downstaged to LT. Respectively, 94 (45%), 60 (29%), and 53 (26%) patients showed complete, extensive, and partial tumor necrosis on histopathology. Three‐year, 5‐year, and 10‐year OS rates were 84%, 77%, and 60%, respectively. Twenty‐four patients developed recurrence, with a median RFS of 120 (95% confidence interval, 69‐150) months. DSM at 3, 5, and 10 years was 6%, 11%, and 16%, respectively. There were no differences in OS/RFS for patients who were bridged or downstaged. RFS was higher in patients with complete/extensive versus partial tumor necrosis (P < 0.0001). For patients with UNOS T2 treated during the study period, 5.2% dropped out because of disease progression. Conclusions: Y90 is an effective treatment for HCC in the setting of bridging/downstaging to LT. Patients who achieved extensive or complete necrosis had better RFS, supporting the practice of neoadjuvant treatment before LT.

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