Although far advanced hepatocellular carcinoma (HCC) is generally considered a contraindication for liver transplantation (LT), biologically favorable tumors among them could show acceptable results. However, it is still unclear which tumors can be treated with LT. Data were collected on adult patients who underwent LT for HCC beyond the Milan criteria in 8 Korean LT centers between January 2000 and June 2013. Far advanced HCC was defined as HCC with the largest tumor ≥ 10 cm, 10 or more tumor nodules, or accompanying macrovascular invasion. A total of 688 patients, including 169 with far advanced HCC, were enrolled in this study. The 5-year overall and recurrence-free survival rates were 60.4% and 55.1%, respectively, for all patients but only 28.7% and 24.8%, respectively, for patients with far advanced HCC (P < 0.001). Both preoperative alpha-fetoprotein (AFP) and protein induced by vitamin K absence or antagonist II (PIVKA-II) were significant risk factors for HCC recurrence after LT. In particular, AFP + PIVKA-II combined was a better predictor than either marker alone. Of all far advanced HCC patients with available AFP and PIVKA-II levels, 45 (30.8%) had low AFP + PIVKA-II (≤300) and their 5-year overall and recurrence-free survival rate were 47.8% and 53.4%, respectively, which were acceptable and significantly superior to those of patients with AFP (ng/mL) + PIVKA-II (nAU/mL) > 300 (21.0% and 10.8%, respectively; P < 0.001). In conclusion, patients with favorable HCC had acceptable outcomes after LT even when their tumors were extremely advanced. AFP + PIVKA-II gave reliable information about the tumor biology of far advanced HCC. Liver Transplantation 00 000–000 2018 AASLD.
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