LAUSR

2 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 Dear Editors: We read with interest the results of the PREMIERE trial by Salem et al, a randomized controlled trial comparing transarterial chemoembolization (TACE) and yttrium-90 (Y90) transarterial radioembolization in patients with hepatocellular carcinoma (HCC) Barcelona Clinic Liver Cancer (BCLC) stages A or B disease. We congratulate the PREMIERE investigators in successfully performing such a challenging trial and furthering our understanding of this complex disease process. Patients with BCLC stages A and B disease are a heterogeneous population with treatment decisions impacted by cancer burden (number and size of tumors), hepatic function, and functional status. But, for those patients eligible for both TACE and Y90 as treatment options, there remains considerable debate as to the best initial therapy for liver transplant candidates. We applaud the authors’ attempt to answer this important question. Unfortunately, for multiple reasons, the trial did not enroll enough patients to meet statistical significance and, ultimately, the number of patients undergoing transplantation was small. The study’s conclusion that Y90 leads to a significantly prolonged time to progression over TACE is encouraging, particularly combined with the safety data presented. However, there remain many unanswered questions in how to manage the BCLC stage A or B patient being considered for liver transplant. During the study, 20 of the 45 enrolled patients underwent liver transplantation. However, the pathologic findings at explant for this population were not presented. We feel that this information would be important to share, because one would expect to find increased pathologic necrosis in the Y90 patients over the TACE patients given the investigator’s conclusion. This finding, if confirmed, would help to validate the increased time to progression noted in the trial in the Y90 group and would support the use of Y90 as the best initial therapy for transplant candidates. There is now an increasing body of knowledge that complete pathologic necrosis (CPN) at explant has a significant impact on post-transplant HCC recurrence rates. However, to date there are no published data comparing the HCC pathologic explant findings of TACE vs Y90 and associated transplant outcomes. At our center, TACE remains the most common locoregional therapy for bridging patients to transplant. Y90 as the initial therapy is becoming more commonplace, particularly for patients who are close to the limits of the Milan criteria. Recently, we performed a retrospective analysis of the explanted livers in a total of 41 patients who underwent