Surgical treatment of hepatocellular carcinoma

Local tumor control is still the most important consideration in the treatment of hepatocellular carcinoma (HCC). Surgical treatments, including liver resection and liver transplantation are, and will remain, the first-line therapeutic strategies for local control in patients with primary HCC. Although aggressive liver resection is often performed for advanced HCC in patients with a large tumor, multiple tumors, or tumors with vascular invasion, liver transplantation is the preferred option, after taking into consideration age and tumor-related factors, when there is poor liver functional reserve. Preventing deterioration in liver function is the second priority in the treatment of HCC. When performing liver resection, extensive removal of noncancerous liver parenchyma during lobectomy or hemihepatectomy, should be avoided as much as possible. Anatomic resection, which refers to systematic elimination of the main tumor with its minute metastases, preserves liver function and is highly recommended. A treatment algorithm based on published evidence is now available, which helps us decide on the most suitable therapeutic option for individual patients, depending on the tumor characteristics and liver functional reserve.     

肝癌手术治疗进展

The incidence of hepatocellular carcinoma (HCC) has increased worldwide over the past two decades. Surgical resection and liver transplantation have been demonstrated as potentially curative treatment options, which could be considered in 30% -40% of HCC patients. Recent advancements of surgical treatment have focused not only on the surgical techpiques, but also the hepatic functional reserve evaluation, resectability assessment and the effects of biological characteristics of tumor on prognosis. There is no single variable to evaluate the hepatic functional reserve accurately. Combined Child-Pugh classification, ICGI5, portal vein pressure detection and remanent liver volume measurement are required prior to liver resection. The 5-year survival rate after liver resection for HCC is about 50%. The results are acceptable for some selected patients that underwent tumor resection with thrombectomy, including HCC with portal vein tumor thrombus or bile duct thrombosis. The choice of local resection or regular hepatectomy is still controversial although the former is commonly performed to treat HCC with cirrhosis, and the latter is applied to HCC patients without liver cirrhosis. The results of liver transplanta-tion for HCC are better than liver resection, and the Milan criteria is generally accepted. Any attempts to expand the selection criteria should be cautious because of organ shortage. Salvage transplantation for intrabepatic recurrence after liver resection may be a good choice in some resectable HCC. The recurrence and metastasis after surgical treatment are the main obstacles to achieve better results. Identification of predictive factors could be helpful to develop prevention strategies. Due to the importance of biological characteristics in tumor recurrence and metastasis, a molecular classification to predict prognosis of HCC patients will lead to a more personalized medicine. Targeting key molecules of biological pathways could optimize the therapeutic modality in HCC.     

挽救性肝移植治疗复发性肝癌

外科手术被认为是最有效的肝癌治疗方式。相对于肝切除,肝移植在5年存活率和复发方面具有明显优势。但由于临床上肝脏供体短缺等因素,故提出了挽救性肝移植（SLT）概念。即在供肝紧缺的情况下,肝癌病人先行肝切除术,术后肝癌复发或发生肝功能衰竭时再行肝移植的治疗策略。国内外各大移植中心对于SLT手术的时机、标准、疗效及影响因素仍然在不断完善和发展。对术前存在门静脉高压症、严重肝硬化、肝功能储备较差的肝癌病人尽可能首选一期肝移植。而对肝功能储备较好、肿块可切除的低危复发风险病人可选择先行一期肝切除,同时进行严密的随访和监测,如证实为肝癌复发符合肝移植标准可行SLT。如果肝癌切除术后病理学检查显示高危复发风险病人应尽快行SLT,不需等到肿瘤复发。     

Liver transplantation for unresectable hepatocellular carcinoma in patients without liver cirrhosis

Summary Hepatocellular carcinoma (HCC) arising in noncirrhotic and nonfibrotic liver (NC‐HCC) is a rare type of malignancy frequently found in healthy young individuals. Partial liver resection is the treatment of choice with expected 5‐year survival rates between 40% and 70%. As a result of absence of any symptom, a considerable number of patients are diagnosed when the malignancy has progressed to an advanced stage and the tumor has turned already unresectable. Some other patients suffer from intrahepatic recurrence after previous liver resection that cannot be re‐resected or locally ablated. In these situations, liver transplantation (LT) may be the only potentially curative treatment. The indication for LT in NC‐HCC patients, however, is not well established. The preliminary results of recent analysis of the European Liver Transplant Registry (ELTR) together with a literature review identified over 150 patients transplanted for NC‐HCC during the last 15 years. In contrast to the historical data, these studies showed 5‐year survival rates at 50–70% in well‐selected patients. Important determinants of poor outcome are macrovascular invasion, lymph node involvement, and time interval of <12 months when LT is used as rescue therapy for intrahepatic recurrence after a previous partial liver resection. Interestingly, outcomes after both liver resection and LT for NC‐HCC are much less influenced by tumor size than is the case with cirrhotic HCC. A large tumor size per se should, therefore, not to be seen as a strict contraindication for performing LT in patients with NC‐HCC.     

肝癌术后复发再次手术的价值及合理选择

对于复发性肝癌,肝切除手术是积极、主动的治疗方法,选择合适的病例可获得良好的效果。复发性肝癌符合Milan标准,美国东部肿瘤协作组（ECOG）评分为0~2分,可考虑行挽救性肝移植（SLT）。如肿瘤直径<5 cm,单个或多个集中在一定范围、位于肝边缘、肝功能尚好的应首选再次肝切除治疗。在设备良好、有经验积累的单位,也可考虑行腹腔镜手术。对于肿瘤直径>5 cm的复发性肝癌,只要肝脏储备功能允许、剩余肝体积（FRLV）足够,应积极争取再次切除。如果已经证实复发性肝癌为单中心起源或合并微血管侵犯（MVI）,建议进行综合治疗,除再次肝切除外,应序贯联合应用射频消融（RFA）、经导管动脉化疗栓塞（TACE）、TACE+RFA、靶向药物等,否则单纯再次肝切除疗效并不理想。如果复发性肝癌合并肝功能失代偿、严重肝硬化、门静脉高压症、肝内脉管主干受侵犯,建议放弃再手术切除而采用其他的非手术治疗方法。     

Optimal Initial Treatment for Early Hepatocellular Carcinoma in Patients with Preserved Liver Function: Transplantation or Resection?

Partial hepatic resection has been the mainstay of curative treatment for hepatocellular carcinoma (HCC) in cirrhotic patients with preserved liver function. Liver transplantation for HCC was initially developed as a treatment option for patients with unresectable tumors associated with Child B or C cirrhosis. However, in recent years, some authors have advocated liver transplantation even for resectable early HCC associated with Child A cirrhosis. Whether transplantation or liver resection is the optimal initial treatment for early HCC in compensated cirrhosis depends on the survival results and also the availability of liver grafts. Recent studies comparing liver resection and transplantation for early HCC in Child A cirrhotic patients demonstrated similar long-term survival. While liver transplantation is associated with a lower tumor recurrence rate, this benefit is counteracted by long-term complications such as immunosuppression related infections and neoplasms. Patients put on transplantation waiting list run a significant risk of tumor progression and dropout, while liver resection is immediately applicable to all. A premature liver transplantation may expose patients to the side effects of immunosuppression earlier than necessary. With the current shortage of liver grafts, advocating primary liver transplantation for patients with early HCC associated with compensated cirrhosis will increase waiting time of transplantation and further increases the chance of dropout. Resection first and salvage transplantation for recurrent tumors or liver failure has been shown to be a feasible strategy in the majority of patients, and this appears to be the optimal strategy with the best use of organs.     

Superiority of transplantation versus resection for the treatment of small hepatocellular carcinoma.

The best therapy for hepatocellular carcinoma (HCC) is still debated. Hepatic resection (HR) is the treatment of choice for single HCC in Child A patients, whereas liver transplantation (LT) is usually reserved for Child B and C patients with single or multiple nodules. The aim of this study was to compare HR and LT for HCC within the Milan criteria on an intention-to-treat basis. Forty-eight patients were treated by LT and 38 by HR. The median time on the waiting list for transplantation was 118 days. The estimated overall survival was significantly higher (P = 0.005) in the LT group than in the HR one. The estimated freedom from recurrence was also significantly higher (P < 0.0001) for LT patients than for HR ones. Indeed, the probability of HCC recurrence after resection was higher than after transplantation achieving 31% and 76% for HR and 2% and 2% for LT at 3 and 5 years after surgery. Multivariate analysis confirmed that transplantation was superior to resection in terms of patient's survival and risk of HCC recurrence. We conclude that LT is superior to HR for small HCC in cirrhotic patients assuming that LT should be performed within 6-10 months after listing to reduce the dropouts for reasons of tumor progression.     

Liver transplantation and conventional surgery for advanced hepatocellular carcinoma

This study intended to discuss the roles of hepatic resection (HR) and liver transplantation (LT) in patients with advanced hepatocellular carcinoma (HCC) through our experience and literature review. For large HCC > 10 cm, HR is regarded as the treatment of choice when hepatic function is preserved. Considering frequent extrahepatic recurrence and acceptable outcome after curative HR, LT has not been recommended. For multiple HCCs, HR has been attempted in different preferences worldwide. HR can offer acceptable survival outcome for patients with small oligo‐nodular HCCs and well‐preserved liver function. Recurrence pattern lowers the applicability of salvage LT, thus primary LT is suggested. For HCC patients with major portal vein tumor thrombus, HR with thrombus removal can be performed, in contrast LT is contraindicated. For HCC with bile duct tumor thrombus, aggressive en bloc resection can lead to prolongation of survival. There is no consensus on transplantability of HCC with bile duct tumor thrombus, but complete resection may provide survival gain after LT. In conclusion, HR and LT have complementary roles, thus they should be associated to rather than being opposed. Multi‐modality treatment strategy especially, for patients with advanced HCC, provides new fields of investigation for diverse indications of HR and LT.     

肝细胞癌肝移植术后复发和转移的研究:单中心经验

目的 研究肝细胞癌肝移植术后复发和转移的临床特点及治疗方法.方法 回顾分析2003年1月至2005年11月收治的95例肝细胞癌肝移植术后肝癌复发转移病例的临床资料.结果 在随访期内,42例(43.2%)患者被诊断为肝癌复发.复发部位最多见于移植肝(32例)、肺(21例)、骨(7例).单因素分析结果显示,肿瘤大小、肿瘤分布、肝硬化背景、术前甲胎蛋白浓度、组织学分期、大血管侵犯6项因素对肝移植术后生存和(或)肝癌复发有明显影响.多因素分析结果显示,肿瘤分布、组织学分期、大血管侵犯是影响术后总体生存率和肝癌复发率的独立危险因素.肝癌复发后的介入治疗及内放疗可延缓肿瘤进展,选择合适病例行复发灶手术切除可最大限度地改善预后.结论 合理选择接受肝移植的肝癌患者可能可以大幅度降低移植术后肝癌的复发率.在现阶段,外科治疗应是目前移植术后复发性肝癌的首选治疗手段.     

Surgical treatment for recurrent hepatocellular carcinoma: Current status and challenges

Primary liver cancer is the sixth most commonly diagnosed cancer and was the third leading cause of cancer deaths worldwide in 2020. It includes hepatocellular carcinoma (HCC) (representing 75%-85% of cases), intrahepatic cholangiocarcinoma (representing 10%-15% of cases), and other rare types. The survival rate of patients with HCC has risen with improved surgical technology and perioperative management in recent years; however, high tumor recurrence rates continue to limit long-term survival, even after radical surgical resection (exceeding 50% recurrence). For resectable recurrent liver cancer, surgical removal [either salvage liver transplantation (SLT) or repeat hepatic resection] remains the most effective therapy that is potentially curative for recurrent HCC. Thus, here, we introduce surgical treatment for recurrent HCC. Areas Covered: A literature search was performed for recurrent HCC using Medline and PubMed up to August 2022. Expert commentary: In general, long-term survival after the re-resection of recurrent liver cancer is usually beneficial. SLT has equivalent outcomes to primary liver transplantation for unresectable recurrent illness in a selected group of patients; however, SLT is constrained by the supply of liver grafts. SLT seems to be inferior to repeat liver resection when considering operative and postoperative results but has the major advantage of disease-free survival. When considering the similar overall survival rate and the current situation of donor shortages, repeat liver resection remains an important option for recurrent HCC.     

Perspective of standardization of surgical treatment for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common malignancies in Japan and worldwide. In recent years, surgical treatment for this disease has made great progress, leading to reduced operative morbidity and mortality. The advances have made it feasible to standardize surgical treatment. Moreover, the public deserves quality treatment ensured by surgical expertise. In these circumstances, the author believes that the following are important issues in the standardization of surgical therapy. 1) Surgical indications and evaluation of hepatic functional reserve, for which the Makuuchi criteria appear useful in principle, must be standardized. 2) The surgical method must be determined. Anatomically systematized resection may be reasonable, although nonanatomical resection may be performed when resection of less extent than the Healey segment is performed. 3) A consensus must be reached on pre- and postoperative adjuvant chemotherapy. Interferon administration liver transplantation may be a promising prophylactic therapy against hepatitis C-related HCC recurrence after curative resection. 4) It is necessary to clarify the long-term survival rate of patients with small HCC who undergo radiofrequency ablation in relation to tumor size, associated liver disease, tumor differentiation, tumor vascularity, etc. Appropriate treatment should be based on an analysis of these four factors. In addition, the issues of surgical indications for vascular tumor thrombus, preoperative portal branch embolization, laparascopic hepatectomy, and also liver transplantation should be discussed, along with perioperative management and postoperative follow-up.     

肝癌切除术后复发的补救性肝移植

目的 评估肝癌患者肝癌切除术后肝癌复发行补救性肝移植术的临床治疗效果及预后影响因素.方法 回顾性分析本治疗组自2000年4月至2008年6月间实施的88例肝癌切除术后复发行补救性肝移植术病例,分析该组病例手术特征、生存状况、病理因素对预后影响.结果 肝癌切除术后复发行补救性肝移植病例平均年龄为52.4±9.2岁(26....     

Feasibility of salvage liver transplantation for patients with recurrent hepatocellular carcinoma

BACKGROUND: Recurrence is the most frequent cause of treatment failure after hepatocellular carcinoma (HCC) resection. Salvage liver transplantation is an alternative treatment for recurrent HCC. The transplantability for patients with recurrent HCC has not been well studied. STUDY DESIGN: This study sought to determine how many patients with recurrent HCC are still candidates for liver transplantation, and to ascertain the possible time from HCC recurrence to the loss of transplantability. In an university hospital setting, 154 of the 252 patients receiving primary HCC resection, from January 1992 through December 1996, had recurrence and were analyzed. The mean follow-up time was 6 years. Among the 154 patients, 74 patients (group 1) were not eligible for liver transplantation according to the Milan criteria, while 80 patients were eligible (group 2). Demographic characteristics of both groups were compared and the curve of transplantability was calculated. RESULTS: When compared with group 1 patients, group 2 patients displayed more cirrhosis (p = 0.007), lower pTNM stage (p = 0.004), were older (p = 0.004), presented with smaller tumors (p < 0.001), and displayed a longer disease-free interval (p < 0.001). In group 1, only 47% (35/74) patients were eligible for liver transplantation at the time of index hepatectomy, in contrast to 84% (67/80) in the group 2 patients, p < 0.001. The median time from HCC recurrence to the time they were no longer transplantable was 38 months. The total time from the index HCC resection to the time of loss of transplantability was 83 months. CONCLUSION: In a cohort of patients after resection for their primary HCC, 33% patients had no recurrence and were not in need for liver transplantation in a mean follow-up of 72 months. About 52% of the patients with recurrent HCC still meet the criteria for liver transplantation. For patients with some certain characteristics, resection of the primary HCC may postpone the time of liver transplantation and prolong the time in which a suitable donor searched, while primary liver transplantation may be considered for those patients with factors of low transplantability after recurrence.     

影响原发性肝癌肝移植治疗的预后因素分析

目的分析影响肝癌肝移植术后生存率和无瘤生存率的危险因素,探讨国内肝移植治疗肝癌的选择标准。方法对67例接受同种异位原位肝移植治疗的原发性肝癌病人的基本资料和肿瘤相关资料包括术前病情分级、血清AFP水平、术前辅助治疗以及肝癌大小、数目、pTNM分期、肿瘤恶性程度分级等因素进行单因素和多因素分析。结果术后1年、2年累积生存率为77%、67%,6个月和12个月无瘤生存率为66%和58%。单因素分析显示对肝癌肝移植术后累积生存率影响有统计学意义的因素为CHILD分级(MELD积分)和肝外大血管侵犯;多因素分析影响肝癌肝移植术后无瘤生存率有统计学义的因素是肿瘤大小、大血管侵犯和肿瘤分化程度。结论影响肝癌肝移植术后生存率的因素仍是术前患者肝功能状态。对存在大血管侵犯的肝癌患者需严格控制肝移植术适应证,而无血管侵犯的患者在选择肝移植治疗时肿瘤大小指标可较米兰标准适当放宽。     

Long-term survival and pattern of recurrence after resection of small hepatocellular carcinoma in patients with preserved liver function: implications for a strategy of salvage transplantation

OBJECTIVE: To evaluate the survival results and pattern of recurrence after resection of potentially transplantable small hepatocellular carcinomas (HCC) in patients with preserved liver function, with special reference to the implications for a strategy of salvage transplantation. SUMMARY BACKGROUND DATA: Primary resection followed by transplantation for recurrence or deterioration of liver function has been recently suggested as a rational strategy for patients with HCC 5 cm or smaller and preserved liver function. However, there are no published data on transplantability after HCC recurrence or long-term deterioration of liver function after resection of small HCC in Child-Pugh class A patients. Such data are critical in determining the feasibility of salvage transplantation. METHODS: From a prospective database of 473 patients with resection of HCC between 1989 and 1999, 135 patients age 65 years or younger had Child-Pugh class A chronic liver disease (chronic hepatitis or cirrhosis) and transplantable small HCC (solitary < or =5 cm or two or three tumors < or = 3 cm). Survival results were analyzed and the pattern of recurrence was examined for eligibility for salvage transplantation based on the same criteria as those of primary transplantation for HCC. RESULTS: Overall survival rates at 1, 3, 5, and 10 years were 90%, 76%, 70%, and 35%, respectively, and the corresponding disease-free survival rates were 74%, 50%, 36%, and 22%. Cirrhosis and oligonodular tumors were predictive of worse disease-free survival. Patients with concomitant oligonodular tumors and cirrhosis had a 5-year overall survival rate of 48% and a disease-free survival rate of 0%, which were significantly worse compared with other subgroups. At a median follow-up of 48 months, 67 patients had recurrence and 53 (79%) of them were considered eligible for salvage transplantation. Decompensation from Child-Pugh class A to B or C without recurrence occurred in only six patients. CONCLUSIONS: For Child-Pugh class A patients with small HCC, hepatic resection is a reasonable first-line treatment associated with a favorable 5-year overall survival rate. A considerable proportion of patients may survive without recurrence for 5 or even 10 years; among those with recurrence, the majority may be eligible for salvage transplantation. These data suggest that primary resection and salvage transplantation may be a feasible and rational strategy for patients with small HCC and preserved liver function. Primary transplantation may be a preferable option for the subset of patients with oligonodular tumors in cirrhotic liver in view of the poor survival results after resection.     

肝癌肝切除术式选择的共识与争议

肝切除依然是目前肝细胞癌主要的治疗方式之一,切除方式包括解剖性肝切除和非解剖性肝切除。由于目前相关的临床研究均为回顾性研究,缺乏随机对照试验,临床实践中究竟是选择解剖性肝切除还是非解剖性肝切除,尚存在争议。肝癌肝切除的成功依赖于肿瘤根治性切除和剩余肝脏功能之间的精准平衡。解剖性肝切除的优势在于完整切除荷瘤肝段（叶）,同时将供应荷瘤肝段（叶）的门静脉系统完整移除,从而最大限度地减少亚临床转移灶,减少肿瘤残留和术后复发,改善长期生存。非解剖性肝切除仅对切缘阴性范围有要求,能够较好地保留无瘤的功能性肝脏组织。综合评估肝脏储备功能和肿瘤相关因素,兼顾手术的安全性和彻底性,将有助于选择合适的手术切除方式。     

Hepatic Resection for Hepatocellular Carcinoma Meeting Milan Criteria in Child-Turcotte-Pugh Class A Patients With Cirrhosis

This study evaluated whether hepatic resection is a reasonable strategy as an initial treatment for hepatocellular carcinoma (HCC) meeting Milan criteria in patients with compensated cirrhosis. From the database of 435 consecutive patients with resection of HCC between July 1994 and May 2007, 213 patients were found to have Child-Turcotte-Pugh class A cirrhosis and HCC meeting Milan criteria, as shown by preoperative image studies. We examined long-term survivals and patterns of recurrence after hepatic resection among those patients. Overall survival rates at 1, 3, 5, and 10 years were 92%, 78%, 69%, and 52%, respectively, and 1-, 3-, 5-, and 10-year disease-free survival rates were 79%, 57%, 44%, and 19%, respectively. Pathological review indicated that 36/213 patients (16.9%) had another nodule and/or gross vascular invasion. Microvascular invasion, tumor size, and histological grade of cirrhosis were independent risk factors for recurrence. Sixty percent of recurrent cases met the Milan criteria. The six patients who underwent living donor salvage liver transplantation (OLT) for intrahepatic recurrence were alive without recurrence at a median of 24 (range = 8-31) months. These favorable data suggest that hepatic resection is a good option for small HCCs in patients with compensated cirrhosis; and salvage OLT may be reserved for patients with recurrences.     

Experiences in liver transplantation for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide. Beside surgical resection, orthotopic liver transplantation (OLT) is not only effective but also the only potentially curable treatment in selected cases of small tumors. We report our experience in 11 male patients transplanted for HCC from August 1998 to July 2002. Selection criteria for OLT were unresectability of the hepatic tumor and severity of the underlying liver disease. The tumor diagnosis was confirmed by histology, imaging techniques, and tumor markers. All patients received an orthotopic liver allograft using a modified piggyback technique. Six of the 11 patients are alive; one died due to acute rejection and four died from recurrent disease. In all four patients with recurrent disease, vascular invasion was shown histologically, whereas only one patient without evidence of recurrence showed vascular invasion. To prevent recurrence after OLT the immunosuppressive regime was adjusted to the underlying disease by early cessation of prednisolone and reduction in the long-term exposure to immunosuppressive drugs. Patients were screened for recurrence by ultrasound and computed tomography. Recurrent HCC were treated symptomatically. OLT is an effective treatment for subgroups of patients with HCC. It might be possible to downstage the liver tumor by chemoembolization and/or radiofrequency ablation and allow the patients to wait for a suitable donor. After OLT the early withdrawal of prednisolone and the reduction of other immunosuppression is feasible. In conclusion, OLT can be a potentially curative therapy for HCC.     

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??Salvage liver transplantation for the treatment of recurrent liver cancer after hepatectomy CHEN Hao, PENG Cheng-hong. Department of Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai200025, China
Corresponding author: PENG Cheng-hong, E-mail: chhpeng@188.com
Abstract Hepatectomy is the mainstay of treatment for hepatocellular carcinoma (HCC) though higher rate of recurrence exists. Liver transplantation is the treatment option for patients with unresectable tumors associated with hepatic malfunction. However, some authors have advocated salvage liver transplantation even for the recurrence of HCC after hepatectomy due to shortage of donor. The first choice of primary hepatectomy or liver transplantation has been argued for recent years. Milan criteria have been obeyed for the performance of salvage transplantation in the most of transplant centers. Only small part of patients have chance to receive salvage transplantation after the recurrence of HCC. Many retrospective investigation or studies of intention-to-treat analysis have revealed that there was similar rate of long survival between primary liver transplantation and salvage transplantation. However, such result has not been confirmed by the data from prospective studies. The consensus is that primary hepatectomy for HCC should be chosen for elder patients associated with good liver function and salvage transplantation could be performed when recurrence occurs.     

Living donor liver transplantation for hepatocellular carcinoma: a single-center preliminary report.

Liver transplantation (LT) is the treatment of choice for early hepatocellular carcinoma (HCC) in patients with end-stage liver disease but is limited by the availability of donor organs. Living donor liver transplantation (LDLT) represents an alternative therapeutic option for patients with disease confined to the liver. Between April 1998 and December 2003, 537 patients underwent liver transplantation in our center. Thirty patients with HCC and associated terminal cirrhosis and 4 patients with tumor recurrence after liver resection who underwent LDLT were reviewed. Nineteen patients (55.8%) met the Milan criteria for LT, whereas 15 patients (44.2%) "exceeded" them. The overall survival rates at 1 and 2 years were 68% and 62%, respectively, with a median follow-up of 41 months (range, 17-64 months). Five patients (14.7%) died in the first 30 days after LDLT. Hospital mortality was significantly correlated with age > 60 years. Four patients developed recurrence between 6 and 35 months after LDLT. Recurrence was significantly related to the presence of more than 3 tumor lesions in our series. In conclusion, LDLT is a promising treatment option for patients with HCC. Even longer follow-up and bigger patients' series are needed to fully assess the benefits of LDLT for HCC patients exceeding the Milan criteria.