Liver Transplantation for Fibrolamellar Carcinoma: National Registry Analysis and Reported Outcomes

Background/Objectives: Liver transplantation may provide prolonged survival in fibrolamellar carcinoma (FLC), but the frequency and timing of post-transplant recurrence, and the basis for patient selection, remain poorly defined. We described the course from listing through long-term follow-up and tested whether routine pretransplant measurements distinguished the recurrence risk. Methods: Scientific Registry of Transplant Recipients data identified separate listing and first-transplant cohorts during 2002-2025. Competing-risk analyses assessed waiting-list outcomes and reported recurrence of the pretransplant tumour. Exploratory recurrence models were internally validated with 500 patient bootstrap samples, with performance assessed only in omitted recipients. Recorded explant tumour extent was examined in the registry's liver explant file. Results: This study included 61 listed candidates and 51 first-transplant recipients; 42 recipients had a pathology-supported discharge diagnosis of FLC. One-year incidence of transplantation was 76.5% (95% CI 65.9-86.6). After a median potential follow-up of 8.1 years, five-year post-transplant survival was 63.3% (95% CI 46.4-76.2). Seventeen recurrences were reported and the three-year cumulative incidence was 26.1% (95% CI 13.9-39.1). Malignancy was the recorded primary cause in 13 of 23 deaths. Laboratory-component and compact clinical models had mean three-year validation areas under the curve of 0.571 and 0.507, and neither reduced prediction error relative to its matched cohort-average prediction. Conclusions: Transplantation was followed by prolonged survival in selected patients with FLC, although reported recurrence was common and sometimes late. Routine pretransplant variables did not identify reproducible recurrence-risk groups. With 51 recipients and 17 recurrences, these estimates are imprecise and the prediction analyses are exploratory; selection should remain multidisciplinary while tumour extent, treatment response and biological markers are evaluated prospectively.