**6. Liver Transplantation for HCC**

The best treatment for both malignancies and the underlying liver condition that most cases of HCC emerge from is generally thought to be liver transplantation. The size and number of tumors determine whether a patient is eligible for a transplant, and standards have been set up to improve outcomes for people with particular types of cancer. The Milan criteria [130], which allow patients with up to three foci of HCC that are less than 3 cm in diameter or one tumor that is less than 5 cm in diameter to receive a liver transplant, are the most often utilized standards globally.

The five-year survival percentage for these patients (75%) was comparable to the survival rate seen in transplant patients at the time who were not cancer patients [130]. The University of California at San Francisco (UCSF) has released its guidelines for liver tumor size regarding tumors measuring less than 6.5 cm, which are observed in one to three tumors. The total tumor diameter should not exceed 8 cm in light of outcome-based evidence with less stringent criteria. There is no negative effect on overall survival in liver cancer [131,132].

Downstaging patients into Milan or UCSF criteria has become a viable method of patient selection as a result of advancements in liver-directed therapy for HCC. What has become clear is that malignancies with a high risk of recurrence after a transplant are those with disease progression despite liver-directed therapy. Scenters can choose patients with better biology and increase patient eligibility without compromising cancer-specific survival by requiring proof of a response to liver-directed therapy prior to the transplant in conjunction with long-term surveillance before deciding to undergo a transplant [133].
