Lecture : Not all the hepatocellular carcinoma (HCC) can safely be treated by liver transplantation. Obviously, there should limitations to overcome HCC recurrence after liver transplantation. Traditionally, Milan criteria has been introduced as a safe edge to select patients who could have less recurrence rate of HCC after liver transplantation. However, this criterion is too limited to cure HCC patients. Thus, many centers have tried to overcome this limitation and expand the criteria. Recently, many centers have been reported their own extended criteria with diverse parameters such as tumor volume, numbers, tumor markers, or SUV on PET. However, merely expanding the indication of liver transplantation for those advanced HCC patients is not enough to make the survival rate improved. The more advanced HCC, we could have the more HCC recurrence after liver transplantation. Thus, several centers have been trying to do down-staging before liver transplantation with various modalities. Waiting period after loco-regional treatment for down-staging should be necessary before liver transplantation to check tumor biology and responsiveness. Few Asian centers that are performing mostly living donor liver transplantation introduced successful down-staging to do liver transplantation even in the patients who had portal vein tumor thrombosis. This could be worthy challenge but still has higher HCC recurrence than the conventional criteria even though the results could be acceptable considering those patients’ survival rate with other treatments. We are still struggling with this issue how are we could go with liver transplantation to treat locally far-advanced HCC. Liver transplant indication should be carefully expanded to give survival benefit to whom have advanced HCC but show good response after locoregional treatment. [References] 1. Lee KW, Park JW, Joh JW, Kim SJ, Choi SH, Heo JS, Lee HH, Lee DS, Park JH, Yoo BC, Paik SW, Koh KC, Lee JH, Choi MS, Lee SK. Can we expand the Milan criteria for hepatocellular carcinoma in living donor liver transplantation? Transplant Proc 2004; 36: 2289-90. 2. Yao FY. Expanded criteria for hepatocellular carcinoma: down-staging with a view to liver transplantation--yes. Semin Liver Dis 2006; 26: 239-47. 3. Kwon CH, Kim DJ, Han YS, Park JB, Choi GS, Kim SJ, Joh JW, Lee SK. HCC in living donor liver transplantation: can we expand the Milan criteria? Dig Dis 2007; 25: 313-9. 4. Takada Y, Ito T, Ueda M, Sakamoto S, Haga H, Maetani Y, Ogawa K, Ogura Y, Oike F, Egawa H, Uemoto S. Living donor liver transplantation for patients with HCC exceeding the Milan criteria: a proposal of expanded criteria. Dig Dis 2007; 25: 299-302. 5. Hoffmann K, Hinz U, Hillebrand N, Radeleff BA, Ganten TM, Schirmacher P, Schmidt J, Buchler MW, Schemmer P. Risk factors of survival after liver transplantation for HCC: a multivariate single-center analysis. Clin Transplant 2011; 25: E541-51. 6. Wigg A, Hon K, Mosel L, Sladden N, Palumbo K. Down-staging of hepatocellular carcinoma via external-beam radiotherapy with subsequent liver transplantation: a case report. Liver Transpl 2013; 19: 1119-24. 7. Han DH, Joo DJ, Kim MS, Choi GH, Choi JS, Park YN, Seong J, Han KH, Kim SI. Living Donor Liver Transplantation for Advanced Hepatocellular Carcinoma with Portal Vein Tumor Thrombosis after Concurrent Chemoradiation Therapy. Yonsei Med J 2016; 57: 1276-81.