Selection criteria for liver transplantation in patients with hepatocellular carcinoma. Eastern and western experiences, and perspectives for the future

Ever since the initial description of the Milan criteria, used for selecting patients with hepatocellular carcinoma (HCC) for liver transplantation (LT), there has been a clear need to go further than solely morphological criteria. Tumours exceeding the Milan criteria, but presenting favourable biological behaviour, might still allow for comparable overall-and disease-free survivals after LT. As it is well established that the presence of microvascular invasion is a major factor that influences HCC recurrence after LT, several serum and tissue biomarkers in addition to imaging studies are attracting wider attention as more refined tools for selecting HCC patients for LT. A thorough review of the recent literature on the subject was conducted. In the future a combination of systemic inflammation markers, biomarkers and morphological criteria may be key to more accurate prediction of HCC recurrence after LT. This may allow LT in patients whose HCC tumours exceed the Milan criteria but have favourable biological behaviour. Further prospective studies are required in order to improve patient selection for transplantation in HCC and these could help a move towards more transparent and improved management.