This opinion piece explores an "ablate and wait" strategy for improving the 5-year recurrence-free outcome of liver transplantation in patients with hepatocellular carcinoma. The Milan criteria delimit by tumor size and number a population of patients who have good survival after liver transplantation. The University of California San Francisco downstaging experience has shown that patients with a tumor burden outside the Milan criteria who undergo tumor ablation and a period of waiting have outcomes that rival those of patients who undergo transplantation within the Milan criteria because the tumor biology is allowed to become apparent by radiological studies during the waiting period. This experience has led to 2 conclusions: first, expansion beyond the Milan criteria should not occur without therapy directed to the tumor followed by a period of waiting to decrease the risk of recurrence, and second, for tumors within the Milan criteria, the same strategy should be considered.
(c) 2010 AASLD.