Hynek Mergental, Rene Adam, Piotr Kalicinski, Bo-G?ran Ericzon, Styrbjorn Friman, Alfred K ningsrainer, Bart van Hoek, Robert J. Porte, the European Liver and Intestine Transplant Association (ELITA). Liver Transplantation and HPB Surgery, UMCG, Groningen, Netherlands; Centre Hepatobiliaire, H?pital Paul Brousse, Villejuif, France; Pediatric Surgery and Organ Transplantation, Children's Memorial Health Institute, Warsaw, Poland; Transplantation Surgery, Karolinska University Hospital, Stockholm, Sweden; Transplantation and Liver Surgery, Sahlgrenska University Hospital, Goteborg, Sweden; General, Visceral and Transplant Surgery, Universitatsklinik, Tubingen, Germany; Gastroenterology, LUMC, Leiden, Netherlands

Background: Partial liver resection is the treatment of choice for hepatocellular carcinoma in non-fibrotic and non-cirrhotic livers (NC-HCC). The role of LT in these patients is unclear. It is also unknown whether the internationally accepted criteria for HCC in cirrhotic livers (Milan criteria) are also applicable to NC-HCC.
Methods: Using the European Liver Transplant Registry (ELTR), we identified 91 patients who underwent LT for NC-HCC between 1995 and 2005. In 46 patients LT was used as rescue therapy for intrahepatic recurrence after previous partial liver resection. In 45 patients LT was the primary therapy and these patients were analyzed here. The impact of patient and tumor characteristics on 5-year survival was analyzed using Kaplan-Meier and multivariate Cox regression analyses.
Results: Male / female ratio was 22/23. Mean (range) age was 36 yr (4-65 yrs). Mean tumor size was 11.4 cm (2.2-30.0). Multifocal HCC was present in 58%, vascular invasion in 49%. Overall 1-, 3-, and 5-year patient survival rates were 86%, 71%, and 46%, resp. Interestingly, survival was not affected by tumor size up to 10 cm. Five-year survival was 69% in patients with HCC < 10 cm and 25% for HCC > 10 cm (p=0.02). Other variables significantly associated with reduced 5-year survival were: macro- and microvascular invasion, and intraoperative red blood cell (RBC) requirement. After multivariate analysis, the only independent predictors of 5-year survival were: mircovascular invasion (HR 5.40; 95%CI 1.03-28.24, p=0.046) and RBC transfusion (HR 1.18; 95%CI 1.03-1.35, p=0.012).
Conclusion: This is the largest reported series of patients undergoing LT as primary therapy for irresectable NC-HCC. The Milan criteria are not a good predictor of posttransplant survival in these patients. Overall 5-year survival in patients with tumor size up to 10 cm is 69%.