Total hepatectomy with transplantation has been regarded as a solution to HCC in patients with cirrhotic livers when hepatic resection is not feasible (37). The careful selection of patients with smaller HCC lesions and without vascular invasion or extrahepatic disease may lead to a post-transplant survival rate similar to that observed for non-HCC indications. In 1996, Mazzaferro et al. (38) reported excellent survival and recurrence outcomes using defined criteria for the selection of HCC candidates for liver transplantation (evidence Level 4). These criteria are now referred to as the Milan criteria (Table 1A). Specifically, cadaveric liver transplantations were performed in patients with a single (<5 cm) HCC nodule or less than three (<3 cm) HCC nodules. The recurrence rate was 8%, and the four-year, recurrence-free survival rate was 83%. To extend the indications for liver transplantation in HCC patients, the UCSF group modified the above criteria as follows: the solitary tumor < 6.5 cm, or three or fewer nodules with the largest lesion <4.5 cm, and the total tumor diameter < 8 cm. These modified criteria are known as the UCSF criteria. According to Yao et al. (39), the UCSF criteria liberalized the Milan criteria for selecting HCC candidates for transplantation, enabling an additional 23% of HCC candidates to undergo transplantation and obtain an outcome very similar to that of patients who fit the Milan criteria (evidence Level 4).
In living-donor liver transplantation (LDLT), where concerns regarding organ sharing are minimal, the criteria for transplantation have been expanded in Japanese and Western countries (Table 1B) (11). LDLT trials for patients with HCC are now ongoing at Japanese centers. According to a nationwide survey by the Japanese Study Group for Liver Transplantation, 208 patients with HCC had undergone an LDLT as of the end of 2002. So far, the long-term results appear favorable, with a five-year survival rate of 62.0% (40) (evidence Level 4).
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