title: Complete pathologic response to pretransplant locoregional therapy for hepatocellular carcinoma defines cancer cure after liver transplantation: analysis of 501 consecutively treated patients.
abstract: OBJECTIVE
  To evaluate the rate, effect, and predictive factors of a complete pathologic response (cPR) in patients with hepatocellular carcinoma (HCC) undergoing locoregional therapy (LRT) before liver transplantation (LT).
  
  
  BACKGROUND
  Eligible patients with HCC receive equal model for end-stage liver disease prioritization, despite variable risks of tumor progression, waitlist dropout, and posttransplant recurrence. Pretransplant LRT mitigates these risks by inducing tumor necrosis.
  
  
  METHODS
  Comparisons were made among HCC recipients with cPR (n = 126) and without cPR (n = 375) receiving pre-LT LRT (1994-2013). Multivariable predictors of cPR were identified.
  
  
  RESULTS
  Of 501 patients, 272, 148, and 81 received 1, 2, and 3 or more LRT treatments. The overall, recurrence-free, and disease-specific survival at 1-, 3-, and 5 years was 86%, 71%, 63%; 84%, 67%, 60%; and 97%, 90%, 87%. Compared with recipients without cPR, cPR patients had significantly lower laboratory model for end-stage liver disease scores, pretransplant alpha fetoprotein, and cumulative tumor diameters; were more likely to have 1 lesion, tumors within Milan/University of California, San Francisco (UCSF) criteria, LRT that included ablation, and a favorable tumor response to LRT; and had superior 1-, 3-, and 5-year recurrence-free survival (92%, 79%, and 73% vs 81%, 63%, and 56%; P = 0.006) and disease-specific survival (100%, 100%, and 99% vs 96%, 89%, and 86%; P < 0.001) with only 1 cancer-specific death and fewer recurrences (2.4% vs 15.2%; P < 0.001). Multivariate predictors of cPR included a favorable post-LRT radiologic/alpha fetoprotein tumor response, longer time interval from LRT to LT, and lower model for end-stage liver disease score and maximum tumor diameter (C-statistic 0.75).
  
  
  CONCLUSIONS
  Achieving cPR in patients with HCC receiving LRT strongly predicts tumor-free survival. Factors predicting cPR are identified, allowing for differential prioritization of HCC recipients based on their variable risks of post-LT recurrence. Improving LRT strategies to maximize cPR would enhance posttransplant cancer outcomes.
authors.affiliation: *Department of Surgery, Dumont-UCLA Transplant and Liver Cancer Centers, Los Angeles, CA; and Departments of †Radiology, and ‡Biomathematics, David Geffen School of Medicine at University of California, Los Angeles, CA.
authors.forename: Vatche G
authors.initials: VG
authors.lastname: Agopian
authors.forename: Maud M
authors.initials: MM
authors.lastname: Morshedi
authors.forename: Justin
authors.initials: J
authors.lastname: McWilliams
authors.forename: Michael P
authors.initials: MP
authors.lastname: Harlander-Locke
authors.forename: Daniela
authors.initials: D
authors.lastname: Markovic
authors.forename: Ali
authors.initials: A
authors.lastname: Zarrinpar
authors.forename: Fady M
authors.initials: FM
authors.lastname: Kaldas
authors.forename: Douglas G
authors.initials: DG
authors.lastname: Farmer
authors.forename: Hasan
authors.initials: H
authors.lastname: Yersiz
authors.forename: Jonathan R
authors.initials: JR
authors.lastname: Hiatt
authors.forename: Ronald W
authors.initials: RW
authors.lastname: Busuttil
mesh_terms: D000328:Adult; D000368:Aged; D001707:Biopsy, Needle; D006528:Carcinoma, Hepatocellular / Q000401:mortality / Q000473:pathology* / Q000601:surgery* / Q000628:therapy; D016208:Databases, Factual; D018572:Disease-Free Survival; D005260:Female; D005500:Follow-Up Studies; D006084:Graft Rejection; D006085:Graft Survival; D006801:Humans; D007150:Immunohistochemistry; D008113:Liver Neoplasms / Q000401:mortality / Q000473:pathology* / Q000601:surgery* / Q000628:therapy; D016031:Liver Transplantation / Q000379:methods* / Q000401:mortality; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D020360:Neoadjuvant Therapy / Q000379:methods*; D011237:Predictive Value of Tests; D011300:Preoperative Care / Q000379:methods; D012189:Retrospective Studies; D018709:Statistics, Nonparametric; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome