Criteria for liver transplantation for hepatocellular carcinoma: what is an acceptable outcome?

The incidence of hepato cellular carcinoma (HCC) and the shortage of grafts restrict liver transplantation (LT) in HCC patients with a low risk of recurrence. The risk of recurrence is mainly related to the presence of vascular invasion which increases in parallel with tumour size and number of nodules. A favourable post-transplant outcome has been observed in patients who meet the empirically defined Milan criteria, namely, a single nodule < 5 cm or two or three nodules each < 3 cm in the absence of macroscopic vascular invasion, based on pre-transplant imaging. These criteria were felt to be too restrictive, leading several centers to propose expanded criteria for LT. However, increasing both the size and number of nodules resulted in an increased risk of recurrence. It has not been demonstrated that loco-regional treatment in HCC patients listed for LT (bridging therapies) improve post-transplant survival. More precise predictors of negative prognostic factors including elevated alpha-feto protein level, poor differentiation and molecular techniques should be considered in order to optimize the use of grafts and achieve zero recurrence.