This objective and practical classification system allows the stratification of LLR comprising the low (group I), the intermediate (group II), and the high (group III) grades.

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Patients undergoing surgery for IHCC are at high risk of R1 resections. In pN0 patients, R1 resection is the strongest independent predictor of poor outcome and a margin of at least 5 mm should be created. The survival benefits of resection in pN+ patients and R1 resection in general are very low.

Liver resection (LR) for hepatocellular carcinoma (HCC) as the first-line treatment in transplantable patients followed by ''salvage transplantation'' (ST) in case of recurrence is an attractive concept. The aim was to identify patients who gain benefit from this approach in an intention-to-treat study. From 1998 to 2008, among 329 potential candidates for liver transplantation (LT) with HCC within the Milan criteria (MC), 138 with good liver function were resected (LR group) from a perspective of ST in case of recurrence, and 191 were listed for LT first (LT group). The two groups were compared on an intention-to-treat basis with special reference to management of recurrences and transplantability after LR. Univariate and multivariate analyses were performed to identify resected patients who developed recurrence beyond MC. Five-year overall and disease-free survival was similar in both groups: LT versus LR group, 60% versus 77% and 56% versus 40%, respectively. Among the 138 patients in the LR group, 20 underwent LT before recurrence, 39 (28%) had ST, and 51 (37%) with recurrence were not transplanted including 21 within MC who were excluded for advanced age, acquired comorbidities, or refusal and 30 (22%) (HEPATOLOGY 2012;55:132-140) L iver transplantation (LT), which is the most effective treatment for early hepatocellular carcinoma (HCC) in patients with chronic liver disease (CLD), is hampered by an imbalance between the increasing number of candidates and an organ shortage.1-4 While the number of patients with HCC is increasing, the main consequence of organ shortage is an increase in the duration of wait time despite a strict limitation of candidates with HCC within the Milan criteria (MC). 5,6 During the wait time, HCC may progress, with a risk of dropout and extension of vascular invasion, which increases the risk of recurrence after transplant. 4,[7][8][9] Alternative curative treatments, which do not compromise transplantation afterwards if needed, include percutaneous ablation and liver resection (LR), which can be performed with a low operative risk and has good long-term survival rates. [8][9][10][11][12] Better liver function assessment, more accurate imaging studies, and refinements in surgical techniques and oncological approach can offer a 5-year survival of approximately 70% in selected patients and do not compromise the possibility to perform LT afterwards in cases of decompensation of cirrhosis and/or tumor recurrence. 11,13,14