LAUSR

Liver transplantation is considered the best curative treatment for patients with hepatocellular carcinoma (HCC). The success of liver transplantation for liver cancer has not only led to an ever-increasing demand for liver grafts but has caused physicians to push the envelope for selection criteria. Increasing evidence demonstrates that there are more transplantable liver cancer patients under extended selection criteria. Expanding the donor pool, especially by developing living donor liver transplantation (LDLT), has largely relieved the organ donor shortage and decreased the drop-off of HCC recipients. The oncological outcome has also been claimed to be comparable with the patients receiving the deceased donor graft. With the expansion of the selection criteria based on the size and number of tumors in the liver, more and more liver cancer patients got the “ticket” to board the boat for liver transplantation. However, cancer recurrence remains a major obstacle for longterm survival after transplantation. Therefore, numerous recurrence warning systems have been proposed for predicting the oncological outcome of liver cancer recipients. The impact of cancer biology itself, which is traditionally considered likely to have disease recurrence, has drawn people’s attention again. The recent time-radiological-response-alphafetoprotein-inflammation score suggested a new prognostic index for HCC patients on the waiting list. It integrated the clinical parameters, the radiological response to locoregional therapies, and the tumor and inflammation markers for the prediction of tumor recurrence. Nevertheless, the debates are ongoing on patient oncological outcome between tumor biology and selection criteria based on the number and size of the tumors. However, the tumor size and number can both be determined before liver transplantation and will not be the only indication to limit us for pushing the envelope of malignancy recurrence. Information on cancer biology, which can be available most likely after transplantation, will only guide us for surveillance and possible prophylactics for cancer recurrence. Recently, increasing evidence reveals that the early phase of systemic and regional inflammatory response after transplantation may also play a critical role on late phase tumor recurrence. Therefore, the liver graft injury itself during transplantation may limit us to push the envelope for liver cancer recipients.