Transarterial chemoembolization in downstaging program for hepatocellular carcinoma prior to liver transplantation: the Bologna work-in-progress experience

Purpose: To assess the efficacy and the safety of transarterial chemoembolization (TACE) on long-term survival and tumor recurrence rate in down-staging patients with hepatocellular carcinoma (HCC) listed for liver transplantation (LT): a new allocation policy still under evaluation. Methods and Materials: We prospectively analyzed with an intention-to-treat principle the outcome of 173 patients listed for LT with a diagnosis of HCC. HCCs were divided into three groups: single nodule <3 cm (T1, 38 patients), single nodule <5 cm or multiple nodules 3 with a diameter <3 cm (T2, 94 patients) meeting the conventional Milan criteria, and the down-stage group (T3, 41 patients): single HCC !6 cm or multiple nodules <6 with a total tumor diameter <12 cm. TACE was performed in a total of 114 patients (65.9%): 15 in T1 (39.5%), 61 in T2 (64.9%), 38 in T3 (92.7%). Results: The rate of LT was equally distributed among the three groups (47.4% T1, 55.3% T2, and 56.1% T3) and after a median follow-up of 21 months, the overall tumor recurrence rate was 12% and the overall patient survival was 83%. The HCC recurrence rate was comparable among the three groups (7.1% T1, 14.3% T2, and 13% T3) and the presence of HCC recurrence did not affect significantly the patients' survival. Conclusion: The pre-operative tumor stage did not affect the patients' survival and in particular the down-stage group had comparable outcome than the other groups. TACE is effective and safe as a down-staging procedure to extend pre-operative selective criteria for HCC patients waiting for LT.