Refining the role of liver transplantation as a curative treatment for hepatocellular carcinoma.

Liver resection (LR) and liver transplantation (LT) are well-established "curative" treatments for hepatocellular carcinoma (HCC), each with advantages and limitations. While LR is widely accepted for patients with preserved liver function, its efficacy is constrained by the risk of postoperative hepatic decompensation and a relatively high recurrence rate. In contrast, LT offers a comprehensive cure by addressing both the tumor itself and underlying liver disease; however, its clinical application is limited by donor shortages, immunosuppression-related complications, and perioperative risks. Recent advancements in perioperative care and immunosuppressive strategies have improved LT outcomes, prompting a re-evaluation of its role in HCC treatment. This review aims to refine the role of LT by focusing on borderline candidates (i.e., patients with multiple tumors, portal hypertension, Child-Pugh B cirrhosis, and elderly individuals) in whom LR can provide benefit. Although treatment decisions must be individualized based on a careful assessment of risks and benefits, LT should be considered as a curative modality for HCC whenever feasible. Broadening the role of LT within the treatment algorithm for HCC, while ensuring the ethical and optimal use of donor organs, may ultimately improve both cure rates and long-term survival in selected patients.