Liver transplantation for hepatocellular carcinoma: Where do we stand?

Table 1 Characteristics and results of the different allocation systems adopted for liver transplantation in hepatocellular carcinoma

Selection system	Year of proposal	Criteria	Survival/years of follow-up
Milan criteria	1996	Single lesion ≤ 5 cm; up to three separate lesions, none larger than 3 cm; no evidence of gross vascular invasion; and no regional nodal or distant metastases	85%/4[8]
University of California, San Francisco criteria	2007	Single nodule up to 6.5 cm or up to three lesions, the largest of which is 4.5 cm or smaller and the sum of the diameters no larger than 8 cm	80.9%/5[9]
Up-to-seven criteria	2009	Sum of size (in cm) of larger tumor plus number of tumors ≤ 7	71.2%/5[12]
Total tumor volume and alpha-fetoprotein criteria	2009	Total tumor volume ≤ 115 cm3 and alpha-fetoprotein ≤ 400 ng/mL, without macrovascular invasion or extrahepatic disease	74.6%/4[11]
Kyoto criteria	2013	≤ 10 tumors; ≤ 5 cm; and des-gamma-carboxy prothrobine ≤ 400 mAU/mL	65%/5[13]
Extended Toronto criteria	2016	Any size or number of tumors, without systemic cancer-related symptoms, extrahepatic disease, vascular invasion, or a poorly differentiated largest lesion at percutaneous tumor biopsy.	68%/5[10]

Table 2 Techniques employed for bridging or downstaging patients with hepatocellular carcinoma before liver transplantation and their efficacy

	Bridging	Downstaging
TACE	0-35% (39)	24%-77% (57)
Radioembolization	NA (49)	11%-43% (57)
RFA	16.8% (50)	NA
SBRT	16.7% (50)	NA
Resection	NA (40, 42)	NA
Combined approach (TACE + RFA or radioembolization)	NA	56% (58)

Bridging column: Percentages (when present) indicate the drop-out rate from list despite bridging therapy; corresponding reference between commas. Downstaging column: Percentages (when present) indicate the success rate with downstaging; corresponding reference between commas. TACE: Trans-arterial chemo-embolization; RFA: Radiofrequency ablation; SBRT: Stereotactic body radiotherapy; NA: Not assessed.