Two cases of pulmonary metastasis after living donor liver transplantation for hepatocellular carcinoma

Orthotopic liver transplantation (OLT) is the only chance of cure for many patients with unresectable but non-metastatic, hepatocellular carcinoma (HCC) and advanced liver cirrhosis. The main shortcoming of this strategy is the increased risk of tumor recurrence after liver transplantation because of either poor selection criteria or the fact that current staging methods cannot reliably detect micro-metastasis. The tumor cell dissemination must have occurred preoperatively or intra-operatively. Immunosuppression represents a risk factor for accelerated tumor growth, so the schedules of the immunosuppressant drugs have been modified through the years, aiming to reduce their dosage to the effective minimum. Many centers currently offer living-donor liver transplant (LDLT) only to patients fitting the Milan criteria1 (patients with single tumor 5 cm or fewer than 3 lesions, none of which are 3 cm). Based on these data, United Network for Organ Sharing (UNOS) also established and recommended the current listing criteria for HCC patients. We present two cases where strict inclusion based on the Milan criteria for selection for LTDT were made; however, both developed a fatal metastasis in the lung within 3 years of transplantation without an obvious involvement of the donor liver.