Liver transplantation for hepatocellular carcinoma

Liver transplantation for hepatocellular carcinoma (HCC) is an effective and potentially curative therapy for carefully selected patients. More than 80% of patients with HCC have underlying cirrhosis and HCC may be multifocal; thus, transplantation is a rational therapeutic option as it offers the potential for treatment of cancer and underlying liver disease. In the non-cirrhotic patient with HCC, surgical resection for amenable lesions is the treatment of choice. Ideal candidates for liver transplantation are those who have small tumors with no metastatic spread, underlying cirrhosis and no serious co-morbid conditions. Since the adoption of the Milan Criteria (one tumor less than 5 cm or up to three tumors, each less than 3 cm), many liver transplant centers have reported excellent recurrence-free survival and overall survival rates for HCC (1–3). The examination of United Network for Organ Sharing data confirmed a steady and significant improvement (5-year patient survival: 1987–1991, 25.3%; 1992–1996, 46.6%; 1997–2001, 61.1%) in the outcome of patients who were transplanted for HCC, indicating that the published criteria, most likely the Milan Criteria, may have contributed to better patient selection and improved survival (2, 3). In fact, in some cases, the post-transplant results for HCC are better than that for non-malignant conditions (4, 5). As the role of liver transplantation for HCC has evolved, several lines of evidence suggest that a modest expansion of the Milan Criteria may be acceptable, although this is not widely practiced.