Liver Transplantation for HCC Beyond Milan

Purpose of the Review: To describe how the field of liver transplantation (LT) for hepatocellular carcinoma (HCC) has expanded beyond the Milan criteria. Recent Findings: The Milan criteria have been the gold standard selection tool for patients with HCC undergoing LT since 1996. However, soon after its creation, the tumor size and number limits imposed by the Milan criteria were expanded upon by new models, such as the University of California-San Francisco criteria and the Metroticket. Still, these models were always limited by radiological inaccuracy in measuring tumor size and number and, more importantly, did not include any measurement of tumor behavior. Biomarkers, such as alpha-fetoprotein and neutrophil-lymphocyte ratio, provide that missing link and act as effective predictors of biological behavior and, therefore, provide an ability to predict tumor recurrence in patients undergoing LT for HCC, allowing for successful expansion beyond Milan. Summary: More recently, newer scoring systems combine morphometric tumor data with markers of biology. These scoring systems, such as the MORAL score, AFP model, RETREAT score, and Metroticket 2.0, are providing the most accurate pre-LT assessments for HCC recurrence and hold the key to the continued improvement of LT outcomes.