Living donor liver transplantation for patients with HCC exceeding the Milan criteria: A proposal of expanded criteria

Background: Optimal indications for living donor liver transplantation (LDLT) for patients with hepatocellular carcinoma (HCC) have yet not been established. The aim of the present study was to determine optimal criteria including categories outside the Milan criteria ( MC) and still with a predictably good outcome. Patients and Methods: Between February 1999 and December 2007, 136 patients with HCC underwent LDLT. Based on preoperative imaging studies, 74 patients met the MC and 62 did not. Results: Overall patient survival rate at 5 years was 70%. Patients who exceeded MC but presented with <= 10 tumors and all <= 5 cm in diameter (n = 33) displayed similar 5-year recurrence rate to those within MC ( 7 vs. 10%). Based on the results of multivariate analysis of risk factors for recurrence, we defined new criteria as n <= 10 and all <= 5 cm and PIVKA- II <= 400 mAU/ml. The 5-year recurrence rate for the 83 patients who met the new criteria was significantly lower than for the 44 patients who exceeded them (5 vs. 61%, p < 0.0001). Similarly, patients who met the new criteria showed a significantly better 5-year survival rate 87 vs. 37%, p < 0.0001). Conclusion: The selection criteria may be safely extended up to n <= 10 and all <= 5 cm in diameter and PIVKA- II <= 400 mAU/ml with acceptable outcomes.