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Page 2 of 14 Cullen et al. Hepatoma Res 2020;6:76 I http://dx.doi.org/10.20517/2394-5079.2020.69

However, the approach and final treatment depends on tumor size, number of tumors and their location, as
well as liver function and performance status. Liver transplantation (LT) has the advantage of removing the
underlying liver disease, reducing the risk for postoperative liver failure and de novo HCC development.
Therefore, LT is the best treatment option for patients with HCC and underlying liver cirrhosis. However,
due to organ scarcity, LT for HCC has been restricted to patients with the highest prospective 5-year
[3]
survival and recurrence rates .
Many have proposed that these criteria might be too restrictive, and that many patients with more
[4,5]
advanced disease would still benefit from LT if organs would be available .

Living donor liver transplantation (LDLT) emerged as a successful strategy to overcome organ shortage
[6]
around the world . As LDLT experience grows, the application of this technique might offer the
opportunity to expand the boundaries of LT to settings in which the organ shortage presents a limitation.
Because the transplant candidate is not competing for deceased donor organs, patients with extended
criteria HCC who could still benefit from LT may have access to the treatment. Moreover, many studies
have already proven that LDLT might even offer a benefit over deceased donor liver transplantation (DDLT)
[7]
to patients fulfilling restrictive transplant criteria . It is the scope of this study to review the role of LDLT
for patients with more advanced HCC and how LDLT allows for safe expansion of HCC transplant criteria.

Staging systems for hepatocellular carcinoma
Currently, there is no universal consensus regarding the best staging system for HCC and its management.
Among the many proposed, two main classification systems are used. The Barcelona Clinic Liver Cancer
(BCLC) classification, the most used in Western countries, and the Hong Kong Liver Cancer (HKLC)
staging system, which was created as a treatment guidance for Asian patients with HCC and is mainly used
in Asian countries. Both classification systems use parameters such as presence of extrahepatic vascular
invasion, tumor size, and number of nodules to stage HCC and provide management recommendations [8-11] .

Despite both classifications being widely used, their differences complicate the decision-making process
[9]
for the transplant team when presented with an advanced HCC. In a recent Brazilian study , 519 patients
diagnosed with HCC were staged according to the BCLC and HKLC system with the aim to analyze
therapeutic approach for different stages. The authors found that between both systems, there was high
general agreement regarding therapeutic management of HCC in the Western population. The highest
agreement was between stages HKLC-I and BCLC-0 (100%) and HKLC-IV and BCLC-C (98.7%). However,
agreement was low in intermediate HCC cases (BCLC-B). The authors found that according to the HKLC,
more than 50% of the BCLC-B stage could have been candidates for curative treatment rather than
palliative treatment recommended by BCLC. Other authors agreed that BCLC is outdated, highly restrictive
with a trend to limit treatment options for more advance tumors, and needs re-evaluation in order to
achieve a proper classification of these patients with a management plan according to current practices .
[10]
It is crucial that HCC staging be conducted in an individualized manner, taking into account biological and
etiological heterogeneity among populations in order to provide the patient with the best treatment option
[9]
available in their case .

LIVING LIVER DONATION FOR HEPATOCELLULAR CARCINOMA
Surgical resection is generally recommended for Child-Pugh Class A cirrhotic patients without significant
[12]
portal hypertension or those with early-stage disease and a single HCC lesion . However, multiple studies
have shown that transplantation can provide superior long-term outcomes over resection [3,12,13] .