| Recommendations |
- LT is recommended as the first-line option for HCC within Milan criteria but unsuitable for resection (evidence high; recommendation strong). Milan criteria are the benchmark for selection of patients with HCC for LT and the basis for comparison with other suggested criteria.
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- Consensus on expanded criteria for LT in HCC has not been reached. Patients beyond the Milan criteria can be considered for LT after successful downstaging to within Milan criteria, within defined protocols (evidence moderate; recommendation weak).
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- Composite criteria that consider surrogates of tumor biology—among which AFP is the most relevant—and response to neoadjuvant treatments—to bridge or downstage tumors—in combination with tumor size and number of nodules, are likely to replace conventional criteria for defining transplantability. Composite criteria should be investigated and determined a priori, validated prospectively, and auditable at any time (evidence low; recommendation strong).
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- Tumor vascular invasion and extrahepatic metastases are an absolute contraindication for LT in HCC (evidence high).
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- The use of marginal cadaveric grafts for LT in patients with HCC has no contraindication (evidence moderate). Prioritizing a cadaveric graft allocation, for patients with or without HCC, within a common waiting list, is complex, and no system can serve all regions. Prioritization criteria for HCC should at least include tumor burden, tumor biology indicators, waiting time, and response to tumor treatment (evidence moderate; recommendation strong).
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- Transplant benefit may need to be considered alongside the conventional transplant principles of urgency and utility in decision making, regarding patient selection and prioritization, depending on list composition and dynamics (evidence moderate; recommendation weak).
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- In LT candidates with HCC, the use of pretransplant (neoadjuvant) locoregional therapies is recommended if feasible, as it reduces the risk of pre-LT dropout and aims at lowering post-LT recurrence—particularly when complete or partial tumor response is achieved (evidence low; recommendation strong).
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- Although the contribution of living donation to LT for HCC in Europe is still marginal, living donor LT for HCC remains an option to be explored in selected patients and in experienced centers, according to waiting list time and dynamics, and within donor-recipient double equipoise principles (evidence low).
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