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Patient selection in liver transplantation for hepatocellular carcinoma

Liver transplantation is the best therapy for selected patients with unresectable hepatocellular carcinoma (HCC). The worldwide incidence of the disease and the success of liver transplantation have produced a high demand, which has led different countries to adopt heterogeneous policies to allocate deceased donor livers for these patients. Even though tumor burden is the criteria with strongest evidence, there is continuous evolution of the interaction of factors that can improve the prediction of disease recurrence and long-term survival, such as tumor size, number of nodules, tumor volume, cancer-related symptoms, alpha fetoprotein serum level, imaging studies, pretransplant biopsy, response to liver-directed therapies and waiting time. In this manuscript, we summarize recent literature on the selection criteria of candidates with HCC undergoing liver transplant evaluation around the world. We review the evidence behind deceased donor liver allocation systems in different countries and the current role of living donor liver transplantation (LDLT). The largest studies come from United Network for Organ Sharing (UNOS) and European databases, however, there is high-impact data coming from Eastern countries with high HCC incidence and high-volume transplant centers, such as China, India, Japan, and South Korea. Soon, a slow shift towards transplant survival benefit in combination with overall survival may be observed in the allocation policies around the world.