| Liver transplantation (LT) is one of the accepted treatment modalities for hepatocellular carcinoma (HCC). In 1996, Mazzaferro et al. suggested that LT should be limited to patients with early HCC characterized by no major vessel invasion and a single tumor less than 5 cm in size, or three or fewer tumors with the largest tumor less than 3 cm in size, referred to as the Milan criteria. They showed that good 4-year overall and recurrence-free survival rates of 75 and 83% respectively, were obtained when LT was performed for early HCC. These Milan criteria are even now widely used to identify suitable candidates for LT with a good prognosis. Nonetheless, many investigators have pointed out that the Milan criteria are too restrictive. Hence, variable expanded criteria for LT for HCC have been suggested. However, it is still unclear which criteria are the most effective for selecting good candidates. In addition, there is no consensus on the acceptable patient survival after LT, especially living donor liver transplant (LDLT). LDLT became one of the important treatment modalities for hepatocellular carcinoma HCC in Asian countries. LDLT for HCC has been increasing and it has recently accounted for about 50% of adult LDLT in our center. The classical indication of LT for HCC in Asian countries is early staged HCC with poor liver function. For resectable cases with good liver function, resection instead of primary LDLT is considered first in most Asian countries. The Milan or UCSF criteria were still used as a selection criteria even in LDLT. However, its indication has been expanded in LDLT because a living graft is dedicated to only one recipient. Recently, the indication of LDLT for HCC has expanded selectively and experience in advanced stage and/or good liver function has accumulated in our center. The tumor biology is important to select optimal indications of LDLT for HCC. Size and number are not enough to stratify the prognosis in LDLT. New biological criteria based on AFP, PIVKAII and PET positivity seemed better to exclude futile LDLT. |
