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Feier. Hepatoma Res 2020;6:75 I http://dx.doi.org/10.20517/2394-5079.2020.68 Page 3 of 5

patients transplanted with LDLT outside MC (c-statistic = 0.8). In fact, patients within MC and with high
[3]
MoRAL scores had higher recurrence rates than patients outside MC and with a low MoRAL score .
When compared to other existent scores, it had the best performance in predicting tumor recurrence after
LDLT. However, it is important to state that 70%-80% of HCC patients have hepatitis B virus infection in
South Korea, so it is difficult to expand these results to Western countries, where hepatitis C dominates
the etiologies for HCC and where most of the transplants are with deceased donors. It would be important
to validate this model in the West, and for DDLT, to aid in the identification of highly selected patients
[15]
beyond MC, who are at a low risk of tumor recurrence .

To predict the risk of death after LT for HCC with DDLT, Mazzafero’s group developed the Metroticket 2.0
score. They concluded that to achieve a 5-year survival of 70%, AFP levels should be below 200 ng/mL, and
the sum of number and size (in cm) of tumors should not exceed 7. These values change according to the
[8]
AFP levels, and the prediction of survival after LT for HCC can be calculated online .
The role of studying tumor biology (biopsy, tumor markers, tumor behavior) and the presence of
[4]
microvascular invasion, which is a surrogate marker of worse survival , could help in patient selection,
[16]
selecting those patients with less aggressive tumors . This approach could expand safely the indications
[3,8]
for LT, keeping the expected 5-year survival above 70% .
In contrast to DDLT, recipient selection for LDLT is not limited by organ allocation systems. When the
first results after LDLT for HCC were published, recurrence rates were higher than with DDLT. Several
concerns were raised about the influence of liver regeneration and suboptimal oncological resection in
[17]
LDLT, suggesting that it could affect recurrence .
[18]
Recently, Zhang et al. conducted a meta-analysis comparing recurrence of HCC in patients transplanted
with liver from living or deceased donors and found a higher recurrence rate of HCC in patients submitted
to LDLT (HR 1.5). In the selected studies, 5-year recurrence-free survival in DDLT patients was between
42% and 100%, and with living donors between 61.6% and 89%. Waiting time was shorter for LDLT in the
majority of the studies, which may be responsible for the higher recurrence rate in LDLT, speculating that
patients with biologically higher risk tumors were selected. Selecting patients with a more aggressive tumor
biology for LDLT, an effect of a shorter waiting list time and also expanding the criteria for LDLT are also
factors that could have an influence on the reported higher recurrence rates in those patients.

[19]
Goldaracena et al. tried to answer the question regarding the observed higher recurrence rates in patients
transplanted using living donors and conducted an intention to treat analysis. The patients were analyzed
according to their inclusion status in the transplant list, as a potential LDLT (pLDLT) or potential DDLT
3
(pDDLT). Patients were included if they fulfilled the Extended Toronto Criteria - total tumor volume ≤ 115 m
and AFP ≤ 400 ng/mL, no macrovascular invasion and no extrahepatic disease. The waiting list time was
significantly shorter for patients listed as pLDLT, with better 5-year survival rates (68% vs. 57%). In the
multivariate regression analysis, having a living donor available was a protective factor against death (HR
0.67). The survival benefit appeared to be predominantly in patients whose tumors fulfilled the MC: 70%
in the pLDLT group and 53% in the pDDLT group. Among patients beyond MC, 5-year survival rates were
62% for those outside MC in both groups. For those patients actually transplanted with a living donor,
5-year recurrence-free survival rates were 80% vs. 72% for those actually transplanted with a deceased
donor.

Results are still conflicting, but HCC recurrence and post-LT survival appear to correlate with biological
tumor behavior and patient selection rather than if the patient was transplanted with a living or deceased
donor. Reports from Eastern countries [3,9,13] , where the majority of patients are transplanted with living