How would you treat a patient with recurrent metastatic HCC 6 years after liver transplant for HCC?

Sadly, I have seen recurrence as far out as 10 years in these situations. Given the high risk of organ rejection (some literature report up to 40%) with immunotherapy and the lack of prospective data, I typically start patients with TKI such as lenvatinib or sorafenib depending on the provider's preference. The biology of this is likely changed such that some of these patients have had good success on these TKIs for longer than 1 year. The decision to initiate on immunotherapy will require a thorough and informed discussion with the patients. If there are clinical trials available to test this question, I would highly encourage participation since it addresses a very important area of clinical significance.