Liver Transplantation Criteria for Hepatocellular Carcinoma: A Systematic Review

Liver transplantation is a curative treatment for selected patients with hepatocellular carcinoma (HCC). While the Milan criteria remain the established benchmark for transplant eligibility, several expanded selection models have been developed to increase access while maintaining acceptable oncologic outcomes. Reported survival and recurrence outcomes across these criteria vary across institutions and regions.

To systematically review published evidence comparing post-transplant survival and recurrence outcomes associated with Milan, UCSF, Kyoto, ASAN (Korean), and Toronto criteria.

A systematic search of PubMed, Cochrane Central, and ScienceDirect was conducted for studies published between 2000 and August 2025. Studies evaluating at least one of the predefined selection criteria in adult HCC patients undergoing liver transplantation and reporting 5-year overall survival and/or recurrence outcomes were included. Findings were synthesized descriptively in accordance with PRISMA guidelines.

Twenty-three studies comprising 6318 patients met inclusion criteria. Milan criteria consistently demonstrated 5-year survival rates exceeding 70% with low recurrence rates across diverse transplant settings. Expanded criteria, particularly UCSF and Kyoto, reported comparable survival outcomes in selected cohorts, though recurrence rates varied by region, donor type, and institutional practice. Biologically driven approaches incorporating AFP and PIVKA-II showed promising results but demonstrated heterogeneity across centers.

Milan criteria remain the most consistently validated framework for liver transplantation in HCC. Expanded criteria may provide acceptable outcomes in carefully selected patients, particularly in experienced centers. Selection strategies should be applied within the context of institutional expertise and regional transplant practice.