In Europe and the United States, approximately 1100 and 1800
liver transplantations, respectively, are performed every year for
hepatocellular carcinoma (HCC), compared with an annual incidence of 65,000 and 39,000 new cases, respectively. Because of organ shortages, proper patient selection is crucial, especially for those exceeding the Milan criteria. Downstaging is the reduction of the HCC burden to meet the eligibility criteria for
liver transplantation. Many techniques can be used in downstaging, including ablation, chemoembolisation, radioembolisation and systemic treatments, with a reported success rate of 60-70%. In recent years, an increasing number of patient responders to downstaging procedures has been included in the waitlist, generally with a comparable five-year post-transplant survival but with a higher probability of dropout than HCC patients within the Milan criteria. While the Milan criteria are generally accepted as the endpoint of downstaging, the upper limits of tumour burden for downstaging HCC for
liver transplantation are controversial. Very challenging situations involve HCC patients with large nodules, macrovascular invasion or even extrahepatic
metastasis at baseline who respond to increasingly more effective downstaging procedures and who aspire to be placed on the waitlist for
transplantation. This narrative review analyses the most important evidence available on cohorts subjected to "extended" downstaging, including HCC patients over the up-to-seven criteria and over the University of California San Francisco downstaging criteria. We also address
surrogate markers of biological aggressiveness, such as
alpha-fetoprotein and the response stability to locoregional treatments, which are very useful in selecting responders to downstaging procedures for waitlisting inclusion.