Living-donor liver transplantation in hepatocellular carcinoma with portal-vein tumor thrombosis

Background: This study evaluated the oncological feasibility of living-donor liver transplantation (LDLT) in patients with hepatocellular carcinoma (HCC) with macroscopic portal-vein tumor thrombosis (PVTT) and to analyze risk factors affecting disease-free survival (DFS) and overall survival (OS). Materials and Methods: We retrospectively reviewed records of 3,098 consecutive patients with HCC and macroscopic PVTT who underwent LDLT at our institution between October 1997 and December 2022; 137 recipients diagnosed with macroscopic PVTT on pre-transplant imaging examination were included (downstaging-responder group, 83; non-responder group, 54). Main outcomes were OS, DFS, and impact of downstaging response on post-transplant outcomes. Results: The median post- LDLT follow-up period was 38.3 (0.5–261.7) months. Vp1, 2, 3, and 4 portal-vein tumor thromboses were present in 51 (37.2%), 36 (26.3%), 36 (26.3%), and 14 (10.2%) patients, respectively. DFS and OS per the PVTT classification were not different ( P = .299 and .188, respectively). In multivariate analysis, poor downstaging response (HR = 2.59, P = .001), PET hypermetabolism (HR = 1.81, P = .038), and larger tumor size (HR = 1.11, P = .0161) were independent recurrence and OS predictors; tumor number (HR = 1.09, P = .0102) and Edmonson–Steiner grade IV (HR = 0.83, P = .0236) additionally predicted recurrence. downstaging responders had better outcomes than non-responders: 1-, 3-, and 5-year DFS, 74%, 68%, and 65% vs 41%, 22%, and 20%, respectively; OS, 96%, 71%, and 67% vs 70%, 40%, and 35%, respectively (P<0.0001). Conclusion: In carefully selected patients with HCC and PVTT who achieved successful downstaging, even including Vp4 cases, LDLT may confer acceptable survival; These findings highlight the importance of preoperative assessment of tumor biology and treatment response in selecting candidates and stratifying risk.