Current Transplant Criteria for Hepatocellular Carcinoma—Overuse or Underuse

In the USA, hepatocellular carcinoma (HCC) has the most rapidly increasing cancer incidence since 1980, has a rate of death that has increased by 43% between 2000 and 2016 and is currently the second most lethal tumor with a 5-year survival of 18%. While the expected 5-year survival after liver transplant (LT) in patients with HCC is attractive at over 70%, LT is limited by extreme shortage of organs and post-LT immunosuppression. Numerous changes to the liver allocation system for HCC in the USA have been applied since 2002. However, for the most part, USA HCC patients continue to receive similar priority for LT despite ample evidence that tumor size and number is only one of many contributors to urgency (i.e. waitlist dropout), utility (i.e. post-LT survival) and LT survival benefit. In this review, we examine where current LT criteria for HCC has resulted in overuse including 1) compensated patients with a single, small, well-treated tumor and 2) patients with HCC amenable to up-front resection. We further examine where current LT criteria for HCC has resulted in underuse including 1) patients with HCC outside of standard criteria but who have favorable markers of tumor biology based on response to local regional therapies, alpha-fetoprotein and other serum biomarker levels, 18F-FDG-PET scan results and tumor biopsy as well as 2) HCC patients with decompensated cirrhosis who have an increased risk of waitlist dropout and thus likely merit additional priority given their increased LT survival benefit.