Liver Transplantation for Hepatocellular Carcinoma after Downstaging or Bridging Therapy with Immune Checkpoint Inhibitors

SIMPLE SUMMARY: Immune checkpoint inhibitors (ICI) have revolutionized the treatment of hepatocellular carcinoma (HCC). In addition to their role in advanced HCC, there is considerable interest in using ICIs in the neoadjuvant setting, either as a downstaging or bridging therapy, prior to potentially curative liver transplantation. In this article, we reviewed all the available literature on ICI use in this context. We postulate that ICIs may be utilized safely prior to liver transplant; however, further research is needed in this area. ABSTRACT: Liver transplantation offers excellent outcomes for patients with HCC. For those who initially present within the Milan criteria, bridging therapy is essential to control disease while awaiting liver transplant. For those who present beyond the Milan criteria, a liver transplant may still be considered following successful downstaging. Since the introduction of atezolizumab as part of the first-line treatment for HCC in 2020, there has been increasing interest in the use of ICIs as bridging or downstaging therapies prior to liver transplant. A total of six case reports/series have been published on this topic, with mixed outcomes. Overall, liver transplantation can be performed safely following prolonged ICI use, though ICIs may increase the risk of fulminant acute rejection early in the post-operative period. A minimal washout period between the last dose of ICI and liver transplantation has been identified as an important factor predicting transplant outcomes; however, further research is needed.