Liver transplantation for hepatocellular carcinoma: alpha-fetoprotein should be included in selection criteria

From the beginning it was clear that the prognosis was related to tumor characteristics in patients liver transplanted for hepatocellular carcinoma (HCC). Thus, selection criteria were needed to identify patients with survival comparable to that of non-malignant indications (1). In 1996, the Milan criteria (MC) were suggested based on size and number of HCC tumors (2). Unfortunately, MC exclude some patients with a good prognosis. These patients may present with a large tumor, however, without features of aggressive biological behavior represented by e.g., vascular invasion or high alpha-fetoprotein (AFP) levels (3-5). Despite this, MC are still recommended in recent European guidelines and as a result, most western centers still use MC (6-8).