The role of LDLT and the intention-to-treat survival benefits over DDLT among HCC patients were demonstrated by the Hong Kong group.9 Lo et al. reported outcomes for a cohort of 51 patients with unresectable HCC who were accepted on lists for both LDLT and DDLT in a single

center. Twenty-five (493) of the 51 patients had voluntary living donors and 26 did not. Median waiting time was significantly shorter for LDLT than for DDLT (24 days vs 344 days, P < 0.005), with a dropout rate of up to 70%. Despite the small size of the cohort, intention-to-treat survival rates of HCC selleck kinase inhibitor patients with voluntary live donors were significantly higher than those of patients without voluntary live donors (4-year survival, 66% vs 31%, P = 0.029). Lo et al. concluded that LDLT would allow more patients to undergo early transplantation and achieve better outcomes, although many complicating factors such as donor voluntarism and selection criteria limit the role that can be played by LDLT. In contrast, the multicenter Adult-to-Adult Living Donor Liver Transplantation Retrospective Cohort Study (A2ALL) reported that LDLT recipients displayed a significantly higher rate of HCC recurrence at 3 years than DDLT recipients (29% vs

0%, P = 0.002), although LDLT recipients had shorter waiting times than DDLT recipients (mean 160 vs 469 days, P < 0.0001).10 Theoretically, the shorter time from listing to transplant allows more patients with HCC to have a chance to be cured by LT, as medchemexpress well as better intention-to-treat survival, if the tumor can be categorized as early HCC at the time of listing. this website The Hong Kong group also reported similar results analyzing 60 early unresectable HCC patients.11 One possible explanation for the increased recurrence of HCC with LDLT

is selection bias for patients with more biologically aggressive tumors in the LDLT group. Mean alpha-fetoprotein (AFP) levels at enrollment (P = 0.023) and at transplant (P = 0.019) in the LDLT group were significantly higher than those in the DDLT group.10 Moreover, the LDLT group tended to include a greater number of patients beyond the MC (62%) than the DDLT group (41%), although no significant difference was apparent (P = 0.05). In the DDLT group, there was adequate time to assess the biological behavior of the tumor, which could exclude patients with a high risk of recurrence before transplantation. Another possible explanation for the observed difference is that LDLT is a less radical oncological procedure due to the surgical techniques—such as greater manipulation of the native liver, which leads to tumor embolization through the hepatic veins—and a need to keep vascular margins closer to the liver. Moreover, promotion of tumor growth and invasiveness by factors upregulated during the natural course of liver regeneration in a partial liver graft may influence the high rate of tumor recurrence after LDLT.