Controversies in criteria for liver transplantation in hepatocellular carcinoma

Purpose of review For patients with hepatic decompensation and hepatocellular carcinoma (HCC) within Milan criteria, liver transplantation provides the best long-term recurrence-free survival. However, there is controversy about the role of liver transplantation in other subgroups, including those with compensated cirrhosis, United Network for Organ Sharing (UNOS) T1 lesions, or HCC exceeding Milan criteria. Recent findings For patients with compensated cirrhosis, surgical resection provides similar recurrence-free survival as liver transplantation and is the most cost-effective approach. Although a 'Wait and not Ablate' approach can facilitate priority listing in most patients with UNOS T1 lesions, nearly 10% will have rapid tumor growth beyond transplant criteria, thereby missing an opportunity for curative therapy. Patients exceeding Milan criteria have higher posttransplant recurrence rates and worse survival than those within Milan criteria, and any potential benefit of liver transplantation to these patients must be weighed against harms to others on the waiting list, particularly in areas with limited donor availability. Although downstaging may help select a subgroup of patients beyond Milan with good tumor biology and better prognosis, limitations of the current literature preclude rigorous evaluation. Summary Until higher quality data become available that demonstrate transplant benefit in expanded criteria patients, liver transplantation should be reserved for patients within Milan criteria.