Sequential, Related Donor Partial Liver Transplantation Followed by Bone Marrow Transplantation for Hepatocellular Carcinoma (HCC)

Inclusion Criteria:

RECIPIENT

1. Histologic diagnosis of liver-confined fibrolamellar or non-fibrolamellar HCC. Ineligible for curative resection or deceased donor liver transplantation by virtue of NOT meeting the Milan criteria or down-staging criteria:

   1. Single viable tumor ≤5 cm in size or ≤3 tumors each ≤3 cm in size based on CT or Magnetic resonance (MR) imaging
   2. Pretransplant alpha fetoprotein (AFP) level of ≤400.
2. Available human leukocyte antigen (HLA)-matched or -haploidentical, living related donor who is willing to donate bone marrow and part of liver. The donor and recipient must be HLA identical for at least one allele (using high resolution DNA based typing) at the following genetic loci: HLA-A, HLA-B, HLA-C and HLA-DRB1. Fulfilment of this criterion shall be considered sufficient evidence that the donor and recipient share one HLA haplotype.
3. Age 16 to 65 years.
4. Normal estimated left ventricular ejection fraction ( \>30% ) and no history of ischemic heart disease requiring revascularization, unless cleared by a cardiologist (as per normal liver and bone marrow (BM) transplant eligibility requirements). Those with an ejection fraction between 30-40%, will require a cardiology consultation and clearance for transplantation.
5. Forced expiratory volume (FEV1) and forced vital capacity (FVC) \> 40% of predicted at the screening visit.
6. Serum creatinine \<2.0 mg/dl
7. For women of childbearing potential, a negative serum or urine pregnancy test with sensitivity less than 50 milli-International unit (mIU)/m within 72 hours before the start of study medication.
8. Use of two forms of contraception with less than a 5% failure rate or abstinence by all transplanted participants for 12 months after the first dose of study therapy. For the first 60 days post-transplant, recipients should be encouraged to use non-hormonal contraceptives due to the potential adverse effect of hormones on bone marrow engraftment.
9. Ability to receive oral medication.
10. Ability to understand and provide informed consent.
11. Must meet all other criteria for listing for liver transplantation

DONOR:

1. HLA-matched or -haploidentical, parent, child, sibling, or half-sibling of the recipient
2. Meets all requirements for live liver donation based on established criteria
3. Ability to understand and provide informed consent for all study procedures including partial liver transplant and bone marrow harvest.
4. Age \< 60 years
5. Body Mass Index (BMI) \<35

Exclusion Criteria:

RECIPIENT

1. Extrahepatic disease at the time of enrollment.
2. Macrovascular invasion by tumor as seen on imaging
3. Anti-donor HLA antibody with a level that produces a positive test on flow cytometric crossmatch. \[Note: patients with a positive flow cytometric crossmatch may undergo desensitization and may become eligible, at the discretion of the protocol investigators, if desensitization decreases the antibody concentration to a level that produces a negative flow cytometric crossmatch.\]
4. Ineligible for liver transplantation per institutional criteria (see Appendix 1)
5. Women who are breastfeeding.
6. History of positive HIV-1 or HIV-2 serologies or nucleic acid test.
7. Active hepatitis B infection as documented by positive Hepatitis B assay
8. Any active, severe local or systemic infection at the screening visit.
9. Use of investigational drug, other than the study medications specified by the protocol, within 30 days of transplantation.
10. Receipt of a live vaccine within 30 days of receipt of study therapy.
11. The presence of any medical condition that the Investigator deems incompatible with participation in the trial.

DONOR

1. Age: less than age 18 or older than age 60
2. BMI \>35
3. History of blood product donation to the recipient
4. Significant cardiovascular disease (per cardiology consultation)
5. Significant pulmonary disease (per pulmonology consultation)
6. Significant renal disease
7. History of diabetes mellitus
8. Ongoing malignancies
9. Severe local or systemic infection
10. Severe neurologic deficits
11. Active substance abuse
12. Untreatable/unstable psychiatric illness
13. History of positive HIV-1 or HIV-2 serology or nucleic acid test.
14. Evidence of prior hepatitis B infection as evaluated by hepatitis B surface antigen (HBsAg), total hepatitis B core antibody, and hepatitis B surface antibody (anti-HBsAb).
15. Positive HBV PCR
16. Positive anti-hepatitis C (HCV) antibodies and a positive serum HCV RNA PCR. All positive HCV antibody results must be assessed by an electroimmunoassay enzyme-linked immunosorbent assay (EIA) assay and confirmed by a quantitative serum HCV RNA assay. Participants with positive HCV antibodies but undetectable serum HCV RNA may be considered for eligibility. Participants with negative anti-HCV antibodies but unexplained liver enzyme abnormalities must undergo a quantitative serum RNA assay to rule out false negative HCV serologies.
17. Autoimmune disease requiring immunosuppressive drugs for maintenance.
18. The presence of any medical condition that the Investigator deems incompatible with participation in the trial.