Advancements of liver transplantation for hepatocellular carcinoma in Korea.

The Milan criteria are still considered the gold standard for patient selection criteria for liver transplantation in patients with hepatocellular carcinoma. However, those criteria may be too strict and thus exclude a significant number of patients who could benefit from liver transplantation. Based on this notion, many expanded selection criteria have been suggested. In Asian countries, where there is a serious shortage of deceased donor organs, living donor liver transplantation accounts for the majority of all liver transplant cases. Because living donor liver transplantation is not controlled by the public allocation system, the indications for living donor liver transplantation can be expanded. In Korea, living donor liver transplantation depends entirely on the discretion of the transplant team and the donor. Hence, Korean transplant centers have had a reasonable amount of experience with liver transplantation for advanced hepatocellular carcinoma. Experiences in Korea show that serum alpha-fetoprotein level, des-gamma-carboxy prothrombin level and positron emission tomography are very useful biomarkers in predicting tumor recurrence after transplantation. Tumors that show favorable levels of these biomarkers might not recur after transplantation despite being morphologically advanced. In addition, combination therapy with mammalian target of rapamycin inhibitors and sorafenib may improve survival even after tumor recurrence. Therefore, in Korea, living donor liver transplantation is considered even for cases of far advanced hepatocellular carcinoma if a recipient has no other effective treatment options and a well-informed donor wishes to willingly participate.