HCC in living donor liver transplantation: Can we expand the Milan criteria?

Background: The tumor biology of hepatocellular carcinoma (HCC) affects recurrence after liver transplantation (LT), but most selection guidelines are based only on tumor size and number. The aim of the study is to evaluate the possibility of expanding the selection criteria in living donor LT (LDLT) without compromising patient survival by adding α-fetoprotein (AFP) in selection guideline. Methods: One hundred thirty-nine patients who received LDLT with the diagnosis of HCC and survived more than 3 months were enrolled. The operability was based on Milan criteria but LT beyond the criteria was performed when requested by the patients and/or the guardian after thorough explanation. Results: The median follow-up duration was 28 months. One-, three- and five-year survival rates were 92.2, 82.6, and 79.9%. There was no survival difference between patients within or beyond Milan (p = 0.76). Serum AFP level >400 ng/ml, tumor size >5 cm, and vascular invasion were significant on univariate analysis, but only vascular invasion was significant on multivariate analysis (p = 0.007). Patients with >3 tumor nodules had better survival compared to ≤3 nodules (p = 0.196). Patient selection using tumor size ≤5 cm and AFP ≤400 ng/ml without limitation of tumor numbers could expand patient selection and improve patient survival. Conclusion: Application of serum AFP level to selection of HCC for LT affords better patient selection criteria.