Section 5. Further expanding the criteria for HCC in living donor liver transplantation: when not to transplant: SNUH experience.

Living donor liver transplant (LDLT) is one of the important modalities to treat hepatocellular carcinoma (HCC) in Asian countries. LDLT for HCC consists of >50% of the total LDLT at Seoul National University Hospital (SNUH). Milan or University of California San Francisco (UCSF) criteria were not considered as absolute selection criteria for LDLT at SNUH. We experienced that some patients with beyond Milan criteria have long-term survival after LDLT. On the contrary, LDLT showed poorer outcome than deceased donor LT (DDLT) in patients with within UCSF criteria in our series. There are several reasons for higher recurrence rate in LDLT such as fast-track selection and rapid regeneration in LDLT. Therefore, the feasibility of conventional criteria based on tumor size and number to predict HCC recurrence after LDLT seemed somewhat different from that of DDLT. We identified significant pre-operative biological factors such as AFP, PIVKAII, and PET positivity. Combination of those biological factors predicted HCC recurrence better than conventional criteria based on size and number. All patients with three risk factors showed 100% recurrence. This group should be excluded regardless of Milan criteria.There have been debates in expanding the criteria in LDLT. Some centers still stick on the expanded criteria that are estimated to yield a 5-year survival of approximately 50%. However, there was no completely tailored criterion to predict HCC recurrence exactly. The survival after recurrence was also different from case by case. Furthermore, the introduction of m-TOR inhibitor and targeted agent improved survival after recurrence. Based on these ideas, we experimentally expanded our indication to the far advanced HCC (HCC larger than 10 cm or more than 10 numbers or with macrovascular invasion preoperatively). The patients with far advanced HCC have usually poor prognosis. However, the selected patients with low AFP (<200 ng/ml), 2-year recurrence free survival was 54.5%.In conclusion, we are now expanding the criteria selectively up to patients with macrovascular invasion if there are no other effective treatment options and the expected survival and risk after LT is acceptable in both recipient and donor. The current absolute contraindication for LDLT in SNUH is extrahepatic metastasis.