title: Multimodal therapy before liver transplantation for hepatocellular carcinoma.
abstract: BACKGROUND
  : The use of orthotopic liver transplantation (OLT) for the treatment of patients with hepatocellular carcinoma (HCC) remains controversial because of the risk of both exclusion from the waiting list due to tumor progression and post OLT HCC recurrence. The aim of the present study was to evaluate the effect of an aggressive HCC treatment during the waiting list time on overall and recurrence-free survival of HCC transplanted patients in a single institutional study.
  
  
  METHODS
  : Since 1991, 40 HCC patients joined the OLT-waiting list. Poorly differentiated HCC cases were excluded, while size and number of nodules were not considered as absolute selection criteria. In all, 90% of the study group had HCC treatment while on the waiting list (transarterial chemoembolization, percutaneous therapies, chemotherapy).
  
  
  RESULTS
  : Only one patient (2.5%) was removed from the waiting list after developing neoplastic portal thrombosis 3 months after listing, while 33 (82.5%) underwent to OLT after a median waiting list time of 11 months (range 3-16 months). On histological examination, 42% of the group did not meet the "Milan criteria" and 42% were pTNM stages III and IV. The median follow-up was 42 months. The 5-year actuarial survival rate was 64% and recurrence-free survival was 91%. HCC recurred in only two patients (6%).
  
  
  CONCLUSIONS
  : The use of routine pre-OLT tumor grading and of an aggressive HCC treatment during the waiting list, in our experience, resulted in a very low risk of pre OLT tumor progression leading to exclusion and of post OLT HCC recurrence.
authors.affiliation: Clinica Chirurgica I, Department of Surgical and Gastroenterological Sciences, University of Padua, School of Medicine, Via Giustiniani 2, Policlinico III Piano, 35128 Padova, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Vitale
authors.forename: Alberto
authors.initials: A
authors.lastname: Brolese
authors.forename: Giacomo
authors.initials: G
authors.lastname: Zanus
authors.forename: Marco
authors.initials: M
authors.lastname: Bassanello
authors.forename: Umberto
authors.initials: U
authors.lastname: Montin
authors.forename: Enrico
authors.initials: E
authors.lastname: Gringeri
authors.forename: Francesco
authors.initials: F
authors.lastname: D'Amico
authors.forename: Francesco Antonio
authors.initials: FA
authors.lastname: Ciarleglio
authors.forename: Amedeo
authors.initials: A
authors.lastname: Carraro
authors.forename: Gianluca
authors.initials: G
authors.lastname: Cappuzzo
authors.forename: Alessio
authors.initials: A
authors.lastname: Bridda
authors.forename: Davide Francesco
authors.initials: DF
authors.lastname: D'Amico
authors.forename: Umberto
authors.initials: U
authors.lastname: Cillo