Evolution of Liver Transplant Selection Criteria and US Allocation Policy for Patients with Hepatocellular Carcinoma

Liver transplantation (LT) is an optimal treatment option for early-stage unresectable hepatocellular carcinoma (HCC) in patients with cirrhosis as it provides a treatment for underlying liver disease as well as a decreased incidence of recurrent cancer compared with alternative treatment strategies. A primary barrier to LT for HCC is the critical shortage of available liver allografts. The system of prioritization and access to deceased donor transplantation for patient with HCC in the United States has continued to evolve, while variable approaches including no additional priority, are in use around the world. While the Milan criteria remain the most well-established pretransplantation selection criteria, multiple other algorithms which expand beyond Milan have been proposed. The current review focuses on liver allocation for HCC as well as the principles and varied models available for pretransplant patient selection.