Profile of Patients Undergoing Liver Transplantation for Hepatocellular Carcinoma at a Brazilian High-Complexity Referral Center: Tumor Biology as a Predictor of Post-Transplant Recurrence

Abstract

INTRODUCTION: Liver transplantation (LT) is considered the optimal curative therapeutic option for most patients with hepatocellular carcinoma (HCC), with 5-year survival rates exceeding 70%. The objective of this study was to analyze the clinical profile of patients undergoing LT for HCC in Brazil and identify prognostic factors associated with survival and recurrence. METHODS: Retrospective study analyzing patients who underwent LT for HCC between January/2015 and December/2024 at a quaternary referral center in Brazil. RESULTS: Among 1321 LT, 423 (32.02%) were performed for HCC. The median recipient age was 61 years, 73% were male, and hepatitis C virus infection was the predominant underlying etiology of cirrhosis. Median physiologic MELD score was 13 and 95.74% of patients were granted MELD exception points. At diagnosis, most patients were within Milan-Brazil criteria (76.59%). Locoregional therapy was performed in 85.10% of patients, mostly as a bridging therapy (65.48%), but also as downstaging procedure (19.62%). From 414 patients within Milan-Criteria before LT, only 255 remained within these criteria on explant pathology. During follow-up, HCC recurrence occurred in 34 patients (8.03%), and the 5-year overall survival rate was 74.6%. Vascular invasion was the strongest predictor of post-transplant recurrence, while microsatellite nodules, poor tumor differentiation, and increasing pre-transplant serum alpha-fetoprotein levels were also associated with recurrence. Overall post-transplant survival was independently associated with recipient age, donor risk index, intraoperative blood transfusion, and prolonged intensive care unit stay. CONCLUSIONS: HCC is a major indication for LT in Brazil. Tumor biology was the principal determinant of post-transplant recurrence, whereas recipient-, donor-, and perioperative-related factors predominantly influenced overall survival.