Liver transplantation as a therapeutic strategy for far-advanced hepatic malignancies: Survival outcomes from the LT-FAM study.

e16238 Background: As liver transplantation (LT) indications expand, it is increasingly explored for select patients with hepatic malignancies far beyond conventional LT criteria. These far-advanced tumors are characterized by very large or innumerable lesions, extreme tumor marker elevation, and previously treated extrahepatic metastatic disease. We evaluated oncologic and survival outcomes following LT across five malignancy types. Methods: We retrospectively reviewed patients undergoing LT from 2015–2025 for far-advanced hepatocellular carcinoma (HCC), hilar cholangiocarcinoma (hCCA), intrahepatic cholangiocarcinoma (iCCA), nonresectable colorectal liver metastases (nCRLM), and metastatic neuroendocrine tumors (NET). Far-advanced disease was defined by excessive tumor size or burden, extreme tumor marker elevation, and/or treated extrahepatic metastases prior to LT. Tumor characteristics and survival outcomes/Kaplan–Meier estimation were analyzed. Results: Fifty-six patients underwent LT, 93% via living donors. All malignancy groups demonstrated extensive tumor burden with high rates of multifocal or innumerable hepatic disease and biomarker elevation. Treated extrahepatic metastases were present in 55% of HCC and 29% of nCRLM recipients. Median overall survival was 2.7 years for HCC, 1.9 years for hCCA, 2.6 years for iCCA, 2.4 years for nCRLM, and 6.8 years for NET. Recurrence ranged from 18–64%, and mortality from 9–50%, with NET demonstrating the most favorable outcomes. Conclusions: In carefully selected patients with hepatic malignancies far exceeding traditional LT criteria, LT, predominantly via living donor pathways, may achieve meaningful survival despite high-risk tumor features. These findings support the feasibility of LT within an expanding transplant oncology paradigm and emphasize selection strategies guided by tumor biology rather than conventional criteria alone. HCC N=11 hCCA N=14 iCCA N=11 nCRLM N=14 NET N=6 Age at Transplant, years (median) 31 46 59 53 58 Sex (n, %Male) 4 (36%) 10 (71%) 7 (64%) 11 (79%) 6 (100%) Living Donor Liver Transplant (n, %) 11 (100%) 13 (93%) 11 (100%) 14 (100%) 3 (50%) Number of hepatic lesions (n, %) 1-3 4-7 8-10 Innumerable 3 (27%)5 (45%)2 (18%)1 (9%) 14 (100%) 9 (82%)1 (9%)1 (9%) 5 (36%)3 (21%)2 (14%)4 (29%) 1 (16%)5 (83%) Max Tumor Diameter (mean, cm) 10 3.6 7.0 6.6 4.8 Extrahepatic Metastatic disease (n, %) 6 (55%) 0 0 4 (29%) 0 Pre-LT Oncologic Treatments (n, %)