Hepatic transplantation for hepatocellular carcinoma: state of the art

Hepatic transplantation offers the best treatment for cure for hepatocellular carcinoma arising in the cirrhotic liver as long as patients and indications are carefully selected. The Milan criteria which became established in the 1990's showed that the best results are obtained when there are three or fewer nodules less than 3 cm in size, or a single nodule less than five cm. in size. Today, these criteria seem to be too restrictive, and indications for surgery can be extended by employing criteria based on macroscopic findings, histology, and even molecular biology. It is necessary not only to better define the limits and indications of therapy but also to keep close watch on patients awaiting transplant to prevent exclusion from the list due to tumor progression. Results can also be improved by decreasing late tumor recurrence with an optimal post-operative immunosuppressive regimen and with adjuvant chemotherapy. The choice of using a living donor or transplanting a liver of marginal quality should also be weighed against the tumor characteristics and the anticipated waiting period for a donor liver. The increasing incidence of hepatocellular carcinoma imposes a need to offer curative therapy to more patients than we are able to do under current circumstances. The treatment strategies for hepatocellular cancer should be multidisciplinary from the start; the use of all available treatment tools including liver transplantation should be better evaluated by multicentric studies.