Conversion to liver transplantation following atezolizumab-bevacizumab for HCC: the Bologna experience.

Introduction

The unprecedented response rates achieved with immune checkpoint inhibitors (ICIs) for hepatocellular carcinoma (HCC) paved the way for possible downstaging or conversion strategies. However, uncertainties remain regarding the optimal timing for ICI discontinuation before liver transplantation (LT) and the risk of graft rejection.

Methods

Post-hoc analysis of prospectively collected data from two hepatology centers in Bologna (2022-2025). Patients received atezolizumab-bevacizumab (AB) for unresectable HCC not suitable for loco-regional therapies. We report the proportion of patients who were successfully downstaged and their follow-up data. Eligibility for LT was discussed in a multidisciplinary team.

Results

Among 108 patients treated with AB (84.1 % were male, 44.8% had macrovascular invasion and 21.5% started with an AFP>400), 35 (32.4%) achieved an objective response. Eight patients (7%) underwent LT after achieving a complete radiological response in 3 cases and a partial response in the remaining 5. When considering only the population <75 year-old and without metastatic disease at the start of AB (n=49), the conversion rate to LT was 16.3%. Objective response was the only variable associated with conversion, while no baseline variable predicted this outcome. The median AB duration before LT was 17.6 months. The median time between atezolizumab discontinuation and LT was 111 days (range 56-134). No graft rejections were observed under standard immunosuppressive protocols After a median post-LT follow-up of 9.5 months, no HCC recurrences were observed.

Conclusions

Conversion to LT is feasible in a non-negligible part of patients receiving immunotherapy. No graft rejections were observed after a 2-months withdrawal of ICIs. Data on post-LT recurrence are still preliminary, yet encouraging.