Indications and limitations of liver transplantation for hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is the most common primary malignant tumor of the liver and one of the most common malignancies worldwide, accounting formore than 1million deaths annually [1,2]. It is a major cause of death among patients with cirrhosis [1]. Identification of tumors early in the course of disease appears to be important for treatment but remains difficult to accomplish. Awareness of the potential for cirrhosis-associated HCC has led to the establishment of screening programs using ultrasonography, CT,MRI, and the measurement of a-fetoprotein (AFP) levels in high-risk populations [3,4].Without treatment the prognosis is dismal, withmedian survival times of 6 to 9 months [5]. Hepatic resection is generally accepted as the treatment of choice, with a reported survival rate of up to 50% at 5 years [6–8]; however, poor underlying liver function and advanced tumor stage preclude traditional hepatic resection in most patients with HCC. With asymptomatic lesions identified in increasing numbers of patients and with the development of new medical and surgical techniques, approaches to the treatment of cirrhotic patients with HCC have changed. Low surgical mortality rates are reported in cirrhotic patients undergoing resection [9]; however, because of advanced tumor stage at presentation and hepatic dysfunction, less than 20% to 25% of patients are candidates for resection. In addition, even when surgical resection can be performed successfully, up to 50% of patients develop intrahepatic recurrences in the remnant liver within 5 years. These recurrences occur because of vascular invasion