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Liver Transplantation for Hepatocellular Carcinoma Outperform Other Populations in the New Hepatitis C Era

Background: Long term results of HCC liver transplants (LTx) in the recent era of direct-acting antivirals (DAA) against hepatitis C (HCV) are not available. We aimed to examine the access, treatments and cure rates with DAA’s utilized in HCC LTx with HCV. Secondarily, we aimed to determine the long term impact of the Liver Cancer Program and DAA therapies on survival of HCC LTx.

Methods: A retrospective analysis of 4 eras of transplantation for HCC/HCV LTx at a single center: Era 1 (’97-2001), 2 (2002-06), 3 (2007-10), and Era 4 (2011-15). In 2011, utilization of first generation DAA’s began, as well as a fully revamped liver cancer program. By 2012, second generation DAA’s were used. All eras were examined for patients that died prior to reaching DAA’s (Era 4). Era 1 to 4 had 2, 20, 47 and 67 HCC/HCV patients, respectively. All DAA treatments in this study were post liver Tx. Kaplan Meier methodology, Log rank and Chi-square was utilized

Results: There were 136 HCC/HCV liver Tx out of 233 liver Tx for HCC during entire time period. More patients Era 3 (41/47=87%) vs. Era 1 and 2 (10/22= 45%) were able to reach the DAA era (p= 0.0002). More patients in Era 4 (22/67=32.8%) were treated with DAA’s than in Era 3 (8/47=17.7%) and in Era 2 (2/20= 10%, p= 0.04). [Era 3 vs 4, p=0.059]. More patients were cured in Era 4 (22/67= 32.8%) vs. Era 3 (7/47=14.8, p=0.03). Improvement across the 4 eras of liver Tx for HCC was statistically significant (Log Rank 0.0018). The 3-year survival of 89 patients in Era 4 was 87.3% compared to 68% for Era 3. Forty-nine patients have already reached that endpoint.

Conclusion: Conclusions: The superiority of Era 4 HCC liver Tx is impressive, with a 19% survival improvement. Decay after the first year was only 3.8% / year. This era coincides with the beginning of DAA’s and the revamped liver cancer program, both significantly improving survival. Contributions from Hepatitis C therapies on overall survival of HCC LTx are unquestionable. One third of HCV infected HCC patients were treated and cured. All (100%) were cured since 2011. However, other factors in the liver cancer program also contributed: better bridge therapies, adjuvant therapies, patient selection, among others. Hepatocellular carcinoma liver Tx recipients are outperforming other liver Tx recipients, and are comparable to HCV alone.