Complete Pathologic Response Linked to Better Survival After Liver Transplantation for HCC

An observational study in Annals of Surgery examined complete pathologic response (cPR) and post-transplant outcomes among 7,398 patients with hepatocellular carcinoma identified in the United Network for Organ Sharing database from 2012–2024. Investigators defined cPR as no viable tumor on explant pathology and assessed treatment-specific response rates, predictors of response, and overall and recurrence-free survival.

Overall, 2,167 recipients (29.3%) achieved cPR. Five-year overall survival was 86.6% among those with cPR versus 77.4% without it; recurrence-free survival was 76.9% versus 63.1%. Response rates were 41.2% with yttrium-90, 36.4% with ablation, and 24.0% with transarterial chemoembolization. In multivariable analysis, yttrium-90 and ablation were associated with higher odds of cPR, whereas greater tumor burden and elevated alpha-fetoprotein were associated with lower odds.

Imaging–pathology concordance was only 30.5%, and imaging overestimated response in 42.6% of cases. These findings highlight limitations of imaging-based response assessment and support the prognostic relevance of explant pathology. However, the observational design cannot establish that a particular locoregional treatment causes better response or survival. Because the cohort comprised transplant recipients, the findings do not directly describe outcomes for all waitlisted patients.