ORIGINAL PAPER Liver Transplantation in the Setting of Hepatocellular Carcinoma and Portal Vein Thrombosis: A Challenging Dilemma? Georgios C. Sotiropoulos Æ Arnold Radtke Æ Klaus J. Schmitz Æ Ernesto P. Molmenti Æ Tobias Schroeder Æ Fuat H. Saner Æ Hideo A. Baba Æ Ioannis Fouzas Æ Christoph E. Broelsch Æ Massimo Malago ´ Æ Hauke Lang Received: 19 February 2007 / Accepted: 27 October 2007 / Published online: 14 December 2007 Ó Springer Science+Business Media, LLC 2007 Abstract Background Portal vein thrombosis (PVT) represents a potentially unfavorable prognostic factor in liver transplantation (LT) for hepatocellular carcinoma (HCC). However, it is frequently difficult to establish preoperatively whether the thrombus is associated with tumor invasion or with stagnant flow. The purpose of this study was to further address this controversial issue. Patients and methods We evaluated 12 consecutive patients who underwent liver transplantation for HCC in the setting of PVT. Results The origin of PVT in HCC patients could be accurately evaluated in 58% of the patients. Forty-two percent of patients had no evident portal vein invasion and only 17% of cases had tumor thrombi. One-third of patients experienced tumor recur- rence within the first posttransplant year, and one-third of patients became long-term survivors (median survival of 36 months) with no evidence of tumor recurrence. One- year survival was 92%. Nine patients are currently alive after a median follow-up period of 25 months. Conclusions PVT in the setting of HCC is characterized by poor patient outcome. However, a respectable number of instances are not accurately evaluated preoperatively, making the deci- sion to exclude these patients from LT sometimes a challenging dilemma. Keywords Liver transplantation Á Hepatocellular carcinoma Á Portal vein thrombosis Á Vascular invasion Á Tumor recurrence Á Milan criteria Á UCSF criteria Á AFP Á Tumor differentiation Abbreviations AFP Alpha fetoprotein CTM Cirrhosis-related thrombotic material DDLT Deceased donor full-size liver transplantation HCC Hepatocellular carcinoma LDLT Live donor liver transplantation LT Liver transplantation MELD Model for end stage liver disease NTM No thrombotic material PVT Portal vein thrombosis PVTT Portal vein tumor thrombi RFA Radio-frequency ablation SLT Deceased donor split liver transplantation TACE Transarterial chemoembolization TTM Tumor-related thrombotic material UICC Union International Contre le Cancer Introduction Liver transplantation (LT) has become the optimal treat- ment for hepatocellular carcinoma (HCC) in the setting of cirrhosis. The introduction of the Milan criteria by Mazzafero et al. [1] in 1996 resulted in 5-year survival rates almost comparable to those of patients transplanted for nonmalignant indications [2–4]. Although various G. C. Sotiropoulos (&) Á A. Radtke Á E. P. Molmenti Á F. H. Saner Á I. Fouzas Á C. E. Broelsch Á M. Malago ´ Á H. Lang Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Hufelandstr. 55, Essen 45122, Germany e-mail: Georgios.sotiropoulos@uni-due.de K. J. Schmitz Á H. A. Baba Institute of Pathology and Neuropathology, University Hospital Essen, Hufelandstr. 55, Essen 45122, Germany T. Schroeder Department of Diagnostic and Interventional Radiology, University Hospital Essen, Hufelandstr. 55, Essen 45122, Germany 123 Dig Dis Sci (2008) 53:1994–1999 DOI 10.1007/s10620-007-0099-4