# Immunotherapy downstaging to transplant with a safe washout

Source: https://onco.cc/ideas/idea-hcc-io-before-transplant/  
OnCo record `idea-hcc-io-before-transplant` (Idea). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Use immunotherapy to shrink liver cancer enough for a transplant, and find the safe gap between the last dose and surgery so the new liver is not rejected.

## Summary

The idea is to use checkpoint inhibitors such as nivolumab or atezolizumab to shrink hepatocellular carcinoma enough for liver transplantation, and to define the safe gap between the last dose and surgery so the new liver is not rejected. Checkpoint inhibitors persist on T cells for months, so the risk is time-dependent and measurable; case series report rejection when PD-1 antibodies are given within weeks of transplant, others successful downstaging. The hypothesis is that a washout of at least three months, timed by receptor occupancy or ctDNA, allows safe transplantation with recurrence-free survival equal to conventionally downstaged patients. The test is a prospective single-arm trial with protocolised washout and biopsy-proven rejection as the safety endpoint.

## Fields

- Kind: Idea
- Last checked: 2026-09-07
- Hypothesis: A washout of at least three months after PD-(L)1 blockade, with pre-transplant PD-1 receptor-occupancy or ctDNA-guided timing, allows safe transplantation with recurrence-free survival equal to conventionally downstaged patients.
- Rationale: Checkpoint inhibitors persist on T cells for months; the immunologic risk is time-dependent and measurable.
- Proposed test: Prospective single-arm trial with protocolised washout and biopsy-proven rejection as the primary safety endpoint; compare to historical downstaging cohorts.
- Maturity: early-clinical

## Sources

- Tabrizian et al., PD-1 inhibitor as bridge therapy to liver transplantation? (American Journal of Transplantation 2021): https://doi.org/10.1111/ajt.16448

## Connected records

- cancers: [Early hepatocellular carcinoma (BCLC 0 and A)](https://onco.cc/cancers/hcc-early/), [Hepatocellular carcinoma](https://onco.cc/cancers/hcc/)
- technologies: [Immune checkpoint inhibitors](https://onco.cc/technologies/checkpoint-inhibitor/), [Liver transplantation for cancer (Milan criteria and beyond)](https://onco.cc/technologies/liver-transplant-oncology/)
- drugs: [Atezolizumab](https://onco.cc/drugs/atezolizumab/), [Nivolumab](https://onco.cc/drugs/nivolumab/)
- trials: [A Study Evaluating Atezolizumab and Bevacizumab, With or Without Tiragolumab, in Participants With Untreated Locally Advanced or Metastatic Hepatocell](https://onco.cc/trials/nct05904886/), [CheckMate 9DW](https://onco.cc/trials/checkmate-9dw/), [IMbrave050](https://onco.cc/trials/imbrave050/), [IMbrave150](https://onco.cc/trials/imbrave150/), [Study of Cabozantinib in Combination With Atezolizumab Versus Sorafenib in Participants With Advanced Hepatocellular Carcinoma (HCC) Who Have Not Rece](https://onco.cc/trials/nct03755791/)
- key papers: [Efficacy and Safety of Nivolumab Plus Ipilimumab in Patients With Advanced Hepatocellular Carcinoma Previously Treated With Sorafenib: The CheckMate 040 Randomized Clinical Trial](https://onco.cc/key-papers/paper-nivolumab-hcc-jama-oncol-2020/), [IMbrave150: atezolizumab plus bevacizumab replaces sorafenib as first treatment for advanced liver cancer](https://onco.cc/key-papers/paper-imbrave150-nejm-2020/), [PD-1 inhibitor as bridge therapy to liver transplantation?](https://onco.cc/key-papers/paper-tabrizian-am-j-transplant/), [Updated efficacy and safety data from IMbrave150: Atezolizumab plus bevacizumab vs. sorafenib for unresectable hepatocellular carcinoma](https://onco.cc/key-papers/paper-atezolizumab-hcc-j-hepatol-2022/)

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