Hepato-Gastroenterology 2011; 58:1873-1876 doi 10.5754/hge10367 © H.G.E. Update Medical Publishing S.A., Athens Οriginal Paper 1873 BILIARY TREE Adoption of New Selection Criteria on Living Donor Liver Transplantation for Hepatocellular Carcinoma and their Impact on the Outcome Ayman Z Azzam 1 and Koichi Tanaka 2 1 Lecturer of General Surgery, Department of General Surgery, Alexandria University, Alexandria, Egypt 2 Director, Institute of Biochemical Research and Innovation, Kobe, Japan Corresponding author: Dr. Ayman Zaki Azzam, Liver Transplant Surgeon, King Faisal Specialist Hospital and Research Center, MBC: 72, P.O.Box 3354 Riyaddh 11211, Saudi Arabia; Tel.: +96 6-1-464-7272 Ext 39474, Fax: +96 6-1-442-4817, E-mail:aazzam70@yahoo.com ABSTRACT Background/Aims: In cadaveric liver transplanta- tion, the Milan criteria have been accepted as the se- lection criteria for HCC in considering organ allocation. However, the situation in LDLT is different. Method- ology: This is a retrospective study on 518 recipients who underwent LDLT. The exclusion criteria included HCC with extrahepatic spread and HCC extending to the major hepatic vessels detected during the preop- erative evaluation. Results: HCC was the indication in 96 patients (18.5%); 52/96 patients (54.2%) fulfilled Milan criteria and 44/96 patients (45.8%) did not. The 5-year survival rate among patients fulfilling Milan cri- teria was 40/52 (77.0%) while for those who did not 30/44 (68.0%). Although these results show better sur- vival rates among patients with HCC within the Milan criteria, they are insignificant (p=0.01) and they clearly demonstrate that patients with HCC outside the Milan criteria have nearly the same survival rate as patients with HCC within Milan criteria. Conclusions: Trans- plantation is the best treatment option for patients with HCC if a careful search reveals no extra-hepatic disease. The application of the Milan criteria for all patients with HCC would have denied many patients who can survive after transplantation. In LDLT programs, where the pa- tient has a special living donor, the Milan criteria are not necessarily relevant. Key Words: HCC Recurrence; Milan criteria; Mortality; Microvascular invasion; Macrovascular invasion. INTRODUCTION Hepatocellular carcinoma (HCC) is the most common primary liver malignancy and a leading cause of death (1). Liver transplantation (LT) was recognized as the best treatment option for patients with early HCC and end stage liver disease (2). Introduction of the Milan criteria, by Mazzaferro et al. in 1996 (3), namely, tumors 5cm or less in diameter in patients with single HCC and no more than 3 tumors nodules of 3cm or less in diameter each, in patients with multiple tumors, resulted in 5-year surviv- al rates among HCC patients fulfilling the criteria, almost comparable with those of patients transplanted for non- malignant indications (4-6). The Milan criteria have been accepted as selection criteria for allocation of cadaveric liver to patients with small unresectable HCC (5,7). How- ever, the situation is different in living donor liver trans- plantation (LDLT), in which, graft donation may only de- pend on the donor’s strong will to save the life of a be- loved relative. METHODOLOGY This is a retrospective study on 518 recipients who underwent LDLT at the Liver Transplantation and Im- munology Department, Kyoto University Hospital, from May 1999 to May 2004. Hepatocellular carcinoma (HCC) was the indication in 96/518 cases (18.5%). The inclu- sion criteria were all unresectable HCC, with no limita- tions for the number and size. The exclusion criteria in- cluded HCC with extrahepatic spread and HCC extending to the major hepatic vessels detected during the preop- erative evaluation. Preoperative assessment of all recip- ients included head, chest and abdominal CT and bone scintigraphy. During the operation, tumor localization was confirmed again. Ascites was also collected and sent for cytological study to rule out tumor dissemination. Pa- tients who were diagnosed with TNM stage III or IVa dis- ease before transplantation received epirubicin infusion (chemotherapy) at 10mg/m 2 during the anhepatic peri- od without any critical side effects. Adjuvant chemothera- py was continued after the operation using the same drug and dose, weekly for 10 weeks, for those with TNM stage III or IVa disease when their general condition allowed it. Statistical analysis Statistical calculations for mean values and standard deviations were performed using the SPSS 12.0 soft- ware package (SPSS Inc., Chicago, IL, USA). Results were expressed as the mean and standard deviation (SD) af- ter verification of normal distribution or median (inter- quartile range) for quantitative variables. ANOVA pro- cedure and Pearson correlation coefficient were used to compare between different values, a p<0.05 was consid- ered statistically significant. RESULTS Age of the patients ranged 21.8-70 years (median 52). Hepatocellular carcinoma (HCC) was the indication of liver transplantation in 96/518 cases (18.5%). HCC as-