Imaging-Based Liver Transplant Eligibility in Hepatocellular Carcinoma: Analysis of 1,094 Patients Using Liver Imaging Reporting and Data System and Asia-Pacific Guideline-Based Criteria.

Introduction: Accurate imaging diagnosis is essential for evaluating liver transplantation (LT) eligibility in hepatocellular carcinoma (HCC) patients. This study investigated whether pre-transplant imaging assessment using the Liver Imaging Reporting and Data System (LI-RADS) and Asia-Pacific guideline-based criteria could effectively predict long-term prognosis when determining LT eligibility. Methods: From a prospective registry, we analyzed 1,094 patients with a preoperative HCC diagnosis who had dynamic CT available within 1 month before LT. LT eligibility was assessed with Milan criteria (MC) and Up-to-Seven criteria (UTS). Imaging evaluation was performed using the LI-RADS, Asian Pacific Association for the Study of the Liver, Japan Society of Hepatology, and Korean Liver Cancer Association-National Cancer Center guidelines. We compared HCC-related mortality using competing risk analysis, overall survival, and prognostic performance between imaging-based and pathologic assessments. Results: The cohort comprised 158 (14.4%) anti-HCC treatment naïve patients and 936 (85.6%) patients who received anti-HCC treatments in the pre-LT setting. No significant difference in HCC-related mortality was observed between patients meeting imaging-based MC and pathological MC (5-year HCC-related mortality: 8.6-8.7% vs. 6.6%; all Conclusion: Although some discordance between imaging-based and pathology-based LT eligibility criteria was observed, pre-transplant imaging provided prognostic stratification comparable to pathology. Given that comprehensive pathological assessment is unattainable before LT, imaging-based evaluation using both LI-RADS and Asia-Pacific guidelines represents a practical and clinically relevant approach for determining LT eligibility.