Living donor versus deceased donor liver transplantation for early irresectable hepatocellular carcinoma

Background: Hypothetical studies that favour living donor liver transplantation (LDLT) for early hepatocellular carcinoma (HCC) assumed a comparable outcome after LDLT and deceased donor liver transplantation (DDLT). The aim of this study was to compare the outcome after LDLT with that after DDLT, and to identify factors that might account for any differences. Methods: The study included 60 patients who met the radiological Milan or University of California at San Francisco (UCSF) criteria and underwent LDLT (43 patients) or DDLT (17). Results: The LDLT group had fewer incidental tumours and a lower rate of pretransplant transarterial chemoembolization but a higher rate of salvage transplantation. Waiting time was shorter and graft weight to standard liver weight (GW: SLW) ratio was lower in this group. The perioperative course, and histopathological tumour size, number, grade and stage were comparable. Median follow-up was 33 (range 4-120) months. The cumulative 5-year recurrence rate was 29 per cent in the LDLT group and 0 per cent in the DDIT group (P = 0.029). A GW: SLW ratio of 0.6 or less, salvage transplantation, three or more tumour nodules, microscopic vascular invasion, and pathological stage beyond the Milan or UCSF criteria were significant confounding risk factors. Multivariable analysis identified salvage transplantation (relative risk 5.16 (95 per cent confidence interval (c.i.) 1.48 to 18.02); P = 0.010) and pathological stage beyond the UCSF criteria (relative risk 4.10 (95 per cent c.i. 1.02 to 16.48); P = 0.047) as independent predictors of recurrence. Conclusion: Despite standard radiological selection criteria based on number and size, patients who underwent LDLT for HCC had more recurrence because of selection bias for other clinical characteristics.