Background/Objectives: Salvage liver transplantation (SLT) is a well-established option for hepatocellular carcinoma (HCC) recurrence after liver resection. Laparoscopic microwave ablation (L-MWA) represents another curative strategy for early-stage HCC. However, its role within this therapeutic framework remains unexplored. Methods: Between 2014 and 2023, we treated 1341 patients with HCC using L-MWA. From this cohort, patients with Child-Pugh class A liver function, HCC within the Milan criteria, no contraindications to transplantation, and ≥12 months of follow-up were selected. SLT failure was defined as non-transplantable recurrence or death, resulting in the loss of a potentially curative therapeutic opportunity. The primary endpoint was overall survival (OS); secondary endpoints included predictors of survival and SLT failure. Results: A total of 341 patients met the inclusion criteria. Five-year OS was 62%. Independent predictors of poorer survival included the presence of cardiac disease or oesophageal varices, a Child-Pugh score of 6, tumour size, and elevated alpha-fetoprotein (AFP) levels. Treatment was successful in 255 patients (74.8%): 102 (29.9%) underwent SLT, 67 (19.6%) received alternative therapies, and 93 (27.3%) remained recurrence-free. Treatment failure occurred in 86 patients (25.2%) due to non-transplantable recurrence or death. Independent predictors of failure included older age, non-HBV aetiology, and elevated AFP levels. Five-year OS rates were 79% in the success group and 22% in the failure group (p < 0.001). Conclusions: A combined L-MWA and SLT strategy is safe and effective, yielding a 62% 5-year OS rate. This approach supports more efficient graft use with a consequent increase in the population transplant benefit. Improved selection may further reduce failure rates.

Background: Non-colorectal cancer liver metastases (NCRLM) represent a therapeutically challenging condition with poorly defined locoregional treatment options. This study evaluates the safety, oncological efficacy, and survival outcomes of microwave ablation (MWA) for NCRLM in a large single-centre series. Methods: Retrospective analysis of a prospectively collected database of patients undergoing MWA for NCRLM between January 2010 and December 2024 at a high-volume hepatobiliary centre. Endpoints were safety, efficacy, Textbook Outcome (TO) achievement, and overall survival (OS). Results: A total of 138 patients underwent 172 MWA across eight primary tumour categories. Major complications (Clavien-Dindo≥3) occurred in 1.8% of procedures, with a median hospital stay of 2 days and a 30-day mortality of 0.6%. Complete response (CR) was achieved in 77% of procedures. TO was achieved in 54% of procedures, with incomplete CR as the primary driver of failure. Five-year OS varied markedly by histology: 100% for GIST, 80.0% for GEP-NET, 44.7% for breast cancer, and 0% for pancreatic adenocarcinoma. The video-assisted approach was associated with superior OS compared to percutaneous ablation (5-year OS 54.4% vs. 26.0%, p=0.00025). Repeat MWA was the most frequent treatment for first hepatic recurrence (43%), and 50.0% of patients achieved non-evidence of disease (NED) at final follow-up. Conclusions: MWA is a safe and repeatable locoregional treatment for NCRLM, with outcomes driven by primary tumour biology. The high rate of liver-dominant recurrence treated with repeat MWA, combined with a final NED rate of 50%, supports MWA as a platform for iterative locoregional disease control in selected patients.

Background: Non-colorectal cancer liver metastases (NCRLMs) represent a therapeutically challenging condition with poorly defined locoregional treatment options. This study evaluates the safety, oncological efficacy, and survival outcomes of microwave ablation (MWA) for NCRLMs in a large single-centre series. Methods: Retrospective analysis of patients undergoing MWA for NCRLM between January 2010 and December 2024 at a high-volume hepatobiliary centre. Endpoints were safety, efficacy, textbook outcome (TO) achievement, and overall survival (OS). Results: A total of 138 patients underwent 172 MWA procedures across eight primary tumour categories via a video-assisted (n = 110, 64%) or percutaneous (n = 62, 36%) approach. Major complications (Clavien–Dindo ≥ 3) occurred in 1.8% of procedures, with a median hospital stay of 2 days and a 90-day mortality of 1.7%. The median follow-up was 24.9 (10.3, 55.8) months. Complete response (CR) was achieved in 77% of procedures and TO in 54%, with incomplete response as the main driver of TO failure. The 5-year OS varied by histology, from 100% (GIST) and 80.0% (GEP-NET) to 44.7% (breast) and 0% (pancreatic adenocarcinoma). The video-assisted ablation was associated with superior OS compared to the percutaneous one (5-year OS 54.4% vs. 26.0%, p = 0.00025). In the multivariable analysis, the percutaneous approach (HR 2.44), ECOG PS ≥ 2 (HR 6.06) and a higher tumour burden score (HR 1.09) independently predicted worse OS, whereas the histological group was not independently associated with OS. Repeat MWA was the most frequent treatment for first hepatic recurrence, and 50% of patients reached no evidence of disease (NED) at last follow-up. Conclusions: MWA is a safe and repeatable locoregional treatment for NCRLMs, with outcomes shaped by tumour biology, disease burden, patient fitness and procedural approach. The high rate of liver-dominant recurrence treated with repeat MWA, combined with a final NED rate of 50%, supports MWA as a platform for iterative locoregional disease control in selected patients.