Comparison of Long-Term Outcomes of Living-Donor Liver Transplantation in Hepatocellular Carcinoma Based on the Milan Criteria After Downstaging According to Degradable Starch Microspheres with Transcatheter Arterial Chemoembolization

Objectives: Hepatocellular carcinoma (HCC) is a disease with an increasing incidence. Liver transplantation (LT) represents the sole curative treatment option. Downstaging (DS) therapy represents an option in selecting suitable candidates for transplantation who initially have tumors exceeding the MC. Consequently, patients undergoing DS for MC have demonstrated comparable survival rates to those who initially met the MC. Degradable starch microspheres with transcatheter arterial chemoembolization (DSM-TACE), a type of TACE, have also been recently introduced in clinical practice. Methods: This retrospective study encompassed 200 consecutive adult patients who underwent living-donor LT for HCC and cirrhosis at two different centers from March 2012 to December 2023. We aimed to compare long-term overall survival (OS) and recurrence-free survival (RFS) among patients with HCC who met the DSM-TACE criteria for MC following diagnosis, those initially within MC, and those outside MC following diagnosis. Results: The OS rate in the MC group was statistically comparable to that in the DS and beyond the MC groups. The MC and DS groups exhibited comparable long-term RFS rates. However, the MC and DS groups showed significantly better RFS rates than the beyond the MC group. Microvascular invasion (MVI), tumor size and number, and the beyond the MC group were identified as significant recurrence risk factors, whereas MVI alone was an independent prognostic factor. Conclusions: Our results showed good long-term OS and RFS in HCC patients following LDLT after staging into MC with DSM-TACE. Additionally, we achieved a more acceptable survival rate compared to other treatments in the group that underwent MC staging after DS.