Supplementary Material for: Feasibility and effectiveness of liver transplantation following immunotherapy patients with hepatocellular carcinoma

Introduction: Immunotherapy is an attractive strategy for downstaging/bridging treatment of hepatocellular carcinoma (HCC) before liver transplantation (LT). This multicentre study reports the feasibility and effectiveness of LT following immunotherapy in a French HCC cohort.
Methods: Clinical, biological, and radiological data were collected at the start and end of immunotherapy, and before LT. Outcomes were evaluated through radiological response post-immunotherapy, recurrence risk (R3-AFP score) on explanted livers, and post-LT complications, aiming to assess primary LT success, overall and disease-free survival.
Results: Twenty-one HCC patients [17 males; median age 62 years (57-64)] were included in the study. Fourteen patients (66.7%) were BCLC-B, and sixteen (76.2%) received atezolizumab/bevacizumab [median 8.5 cycles (4.7 – 14)]. At the end of immunotherapy, 57.1% met Milan-in criteria, and 95.2% had AFP score 2 (p = 0.002). The median interval from last immunotherapy to LT was 5.1 (2.7-9.3) months. All but three patients received standard immunosuppression. Explant pathology showed residual tumours in 71.4%, with 47.6% at high recurrence risk according to R3-AFP score. Two patients experienced allograft rejection, and one (4.8%) had HCC recurrence post-LT. Early adverse events occurred in 6 patients (28.5%), leading to 5 deaths (23.8%). At 12 months, 71.4% were alive without HCC recurrence. Lower overall survival was linked to pre-LT Child-Pugh B class, absence of prior HCC treatment, fewer than 5 immunotherapy cycles, and early post-LT complications.
Conclusion: LT following immunotherapy is feasible in selected HCC patients, although caution is warranted due to the potential but manageable rejection risk. However, high early mortality warrants further investigation in larger prospective series.