Yttrium-90 radioembolization is associated with a lower risk of liver transplant waitlist dropout than chemoembolization in hepatocellular carcinoma.

Abstract

Recent small studies have suggested improved hepatocellular carcinoma (HCC)-related outcomes with trans-arterial radioembolization (TARE) compared to chemoembolization (TACE), although it remains unclear if this leads to superior transplant-related outcomes. Our aim was to compare waitlist outcomes for TARE vs. TACE as first local-regional treatment (LRT) for HCC in the contemporary Median Model for End-Stage Liver Disease (MELD) at Transplant minus 3 (MMaT-3) era with standardized wait times throughout the country.The study cohort comprised of 5677 adult liver transplant candidates from the United Network for Organ Sharing database with at least one approved HCC exception between May 14, 2019 and October 3, 2024, and received first LRT with TACE (50.0%) or TARE (50.0%).The TARE group had a slightly larger proportion of solitary initial tumor (76.4% vs. 70.5%) and median largest tumor size, although aggregate tumor size was similar. The TARE group had a higher proportion receiving only one LRT (80.6% vs. 57.8%) and a higher rate of complete necrosis in the explant (35.3% vs. 20.2%) versus the TACE group. The TARE group had a 22% decreased hazard of waitlist dropout in inverse probability of treatment-weighted competing risk analysis (hazard ratio 0.78, 95% confidence interval 0.69 - 0.89, p<0.001; cumulative incidence at 1 year: 8.9% vs. 11.4%; 2 years: 14.2% vs. 19.0%; 3 years: 16.8% vs. 22.1%) compared to TACE, adjusting for patient and tumor characteristics.In a large national cohort of liver transplant candidates with HCC, TARE compared to TACE as first LRT was associated with higher rates of complete necrosis on explant, lower likelihood of multiple LRTs, and lower risk of waitlist dropout.With nearly all hepatocellular carcinoma (HCC) patients in the US now receiving local regional therapies (LRT), better understanding of the optimal LRT type to achieve tumor control and maintain tumor stage is needed. In this contemporary study of over 5000 patients using the US national database (UNOS), we showed that trans-arterial radioembolization (TARE) may be the preferred bridging therapy over chemoembolization (TACE) based on a significantly lower probability of waitlist dropout after controlling for liver function and tumor characteristics. Additionally, TARE treated patients demonstrated higher probability of complete pathologic response and reduced tumor under-staging on explant, which taken together strongly suggests that TARE is a more effective tumor treatment compared to TACE.

View details for DOI 10.1016/j.jhep.2026.01.008

View details for PubMedID 41580092