Hepatocellular carcinoma: A comprehensive review

Table 3 Clinical practice guidelines for liver transplantation in hepatocellular carcinoma - European Association for the Study of the Liver and European Organization for Research and Treatment of Cancer

Guideline	Level of evidence	Strength of recommendation
Liver transplantation is considered to be the first-line treatment option for patients with single tumors less than 5 cm or ≤ 3 nodules ≤ 3 cm (Milan criteria) not suitable for resection	2A	1A
Perioperative mortality and one-year mortality are expected to be approximately 3% and ≤ 10%, respectively
Extension of tumor limit criteria for liver transplantation for HCC has not been established. Modest expansion of Milan Criteria applying the “up-to-seven” in patients without microvascular invasion achieves competitive outcomes, and thus this indication requires prospective validation	2B	2B
Neoadjuvant treatment can be considered for loco-regional therapies if the waiting list exceeds six months due to good cost-effectiveness data and tumor response rates, even though impact on long-term outcome is uncertain	2D	2B
Down-staging policies for HCCs exceeding conventional criteria cannot be recommended and should be explored in the context of prospective studies aimed at survival and disease progression end-points	2D	2C
Assessment of downstaging should follow modified RECIST criteria
Living donor liver transplantation is an alternative option in patients with a waiting list exceeding six to seven months, and offers a suitable setting to explore extended indications within research programs	2A	2B

Adapted from the EASL-EORTC clinical practice guidelines: Management of hepatocellular carcinoma. J Hepatol 2012; 56: 908. The level of evidence and strength of recommendation are based on the National Cancer Institute classification and GRADE system, respectively. HCC: Hepatocellular carcinoma; RECIST: Response Evaluation Criteria In Solid Tumors.