Source Liver and Multiorgan Transplant Unit - Department of General Surgery, S.Orsola Hospital, University of Bologna, Italy. aleqko@libero.it.

Allocation rules for patients with hepatocellular carcinoma (HCC) awaiting liver transplantation (LT) are a difficult issue in continuous evolution. To reduce tumor progression or down-staging advanced disease, the practice of treating HCC candidates with resection or loco-regional therapies is currently adopted in most transplant centers. The present study is aimed at assessing the effectiveness of bridge therapy in modifying removals from the waiting list for reasons of death/too sick, or tumor progression beyond Milan criteria and in determining post-transplantation outcome. Removal rates for 315 adult HCC patients listed for LT were analyzed and related to response to bridge therapy by means of competing risk analysis. The 3-, 6- and 12-month dropout rates were 3.5, 6.5 and 19.9%, respectively and were significantly affected by the Model for End-Stage Liver Disease score (P=0.032), tumor stage at diagnosis (P=0.041) and response to bridge therapy (P<0.001). The stratification of candidates on the basis of tumor stage and response to bridge therapy showed that T2 tumors, achieving only partial or no-response to bridge therapy, had the highest dropout rates, followed by T3-T4a tumors successfully down-staged (P=0.037). T2 tumors with complete response and T1 tumors had similar dropout rates (P=0.964). Response to bridge therapy significantly affected both the recurrence-rate of 176 transplanted patients (P=0.017) and the overall intention-to-treat survival (P=0.001). In conclusion, response to therapy is a potentially effective tool for prioritizing HCC patients for LT and for selected cases with different risks of tumor recurrence after transplantation.