Table 1.

All-comers and united network for organ sharing (UNOS) downstaging (DS) protocols.

UNOS-DS protocol	All-Comers protocol
Inclusion criteria
Hepatocellular carcinoma (HCC) exceeds Milan criteria but meets one of the following: Single lesions 5.1 to 8 cm 2 to 3 lesions each ≤ 5 cm with the sum of the maximal tumor diameters ≤ 8 cm 4 to 5 lesions each ≤ 3 cm with the sum of the maximal tumor diameters ≤ 8 cm	HCC exceeding UNOS-DS protocol by any of the following: HCC tumor number HCC tumor size Total HCC tumor diameter
Criteria for successful downstaging
Residual tumor size and diameter within Milan criteria (1 lesion ≤ 5 cm, 2 to 3 lesions ≤ 3 cm)
Criteria for DS failure and exclusion from a liver transplant
1. Tumor progression beyond inclusion/eligibility criteria above 2. Extrahepatic disease and vascular disease on cross-sectional imaging 3. Per current UNOS policy, when alpha-fetoprotein (AFP) ≥ 1000, then transplant cannot be performed unless AFP declines to < 500 ng/mL with LRT
Transplant timing
Minimal observation period of 3 mo between successful DS and transplant demonstrating disease stability	Minimal observation period of 6 mo between DS and transplant demonstrating disease stability and approval by review board