*Purpose: Patient selection criteria for living donor liver transplantation(LDLT) with hepatocellular carcinoma are generally wider than those for deceased donor liver transplantation. It is widely accepted that LT should not be performed when a main portal vein tumor thrombus (PVTT) is present. The purpose of this study was to evaluate the feasibility of LDLT for treatment of patients with hepatocellular carcinoma and segmental PVTT.

*Methods: Between January 2005 and December 2016, we retrospectively analyzed 242 patients in a control group (n=184), a microvascular invasion (MVI) group (n=24), and a PVTT group (n=34). PVTT was diagnosed preoperatively when intrathrombus vascularity was evident in the arterial phases of imaging studies (CT or MRI) just before LT. And finally, PVTT was pathologically confirmed in the explant liver. A PVTT below the second-order branch was defined as segmental; a PVTT in the first-order branch was defined as lobar. To assess the risks associated with PVTT, we evaluated recurrence, the disease-free survival (DFS) rate, the overall survival (OS) rate, and various other factors based on the characteristics of patients and tumors.

*Results: Of the 242 patients, 5-year DFS and OS rates were 79.5% and 70.7%. A total of 34(14.0%) patients had PVTT, of whom 7 had lobar PVTT in first-order branches. The control, MVI, and PVTT groups significantly differed in terms of tumor morphology (maximal and total diameters) and biology (alpha-fetoprotein [AFP] and protein induced by vitamin K absence or antagonist II). The control, MVI, and PVTT groups significantly differed in terms of the recurrence, DFS, and OS rates. Especially, lobar PVTT reduced the 5-year DFS and OS rates to dismal and 14.3%, respectively, but segmental PVTT was associated with favorable 5-year DFS and OS rates (63.9% and 50.3%, respectively). We found no statistically significant difference in the DFS and OS rates of patients with MVI alone andsegmental PVTT alone. In patients in the segmental PVTT group with AFP levels of <100 ng/mL, the 5-year DFS and OS rates were 90.9% and 71.3%, respectively.

*Conclusions: Liver transplantation has become one of the most effective modalities by which to treat HCC. Lobar PVTT remains a contraindication for LT. However, the presence of segmental PVTT may be acceptable. To achieve better results, we recommend that the AFP level be considered such as the AFP level is <100 ng/mL when selecting patients with segmental PVTT.

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