Multifocal hepatocellular carcinoma in patients undergoing living-related liver transplantation

Many institutions apply the indications for living-related liver transplantation in patients with hepatocellular carcinoma based on the Milan criteria, which state that transplantation is not indicated when more than three foci of disease are present. However, the relationship between the number of foci identified preoperatively and the number detected on pathologic examination of the surgical specimen is unknown. The case of a 66-year-old Japanese woman with cirrhosis secondary to type C viral hepatitis who developed hepatic failure secondary to multifocal hepatocellular carcinoma is presented. Three foci of hepatocellular carcinoma were identified radiologically preoperatively. Following successful living-related liver transplantation, pathologic examination of the surgical specimen revealed that six foci of hepatocellular carcinoma and one dysplastic nodule were present. Although the number of foci of hepatocellular carcinoma is a predictor of recurrence and > 3 is a relative contraindication to transplantation, lesions undetected radiologically (such as dynamic computed tomography) are unlikely to have metastatic or invasive potential because they have yet to evolve a capillary blood supply and still receive their nutrition via hepatic sinusoids on immunohistochemical and radiological findings. Foci of hepatocellular carcinoma undetected preoperatively are unlikely to effect prognosis when total hepatectomy is performed in the context of living-related liver transplantation.