Liver transplantation for primary liver cancers in the era of transplant oncology

Liver transplantation (LT) remains the most effective curative-intent surgical approach for selected patients with primary hepatic malignancies, owing to its ability to completely replace the diseased liver and address both the tumour and the underlying liver disease. Rather than being determined solely by technical feasibility, transplant candidacy is defined by a dynamic "window of eligibility" based on predicted overall survival and transplant benefit, with repeated assessment of tumour burden, biology, and response to therapy. LT should therefore be viewed as a complex, multi-step process encompassing patient selection, neoadjuvant treatment, graft procurement, surgery, and long-term postoperative management. Neoadjuvant strategies, including bridging, downstaging, and conversion therapies, have become central to patient selection and have expanded transplant eligibility for selected patients with advanced disease through combinations of systemic and locoregional treatments. Following transplantation, minimisation of immunosuppression is essential to balance graft preservation against tumour immune surveillance, although the persistence of antitumour immunity after pre-transplant immunotherapy remains uncertain. Emerging biomarkers, including circulating tumour DNA, circulating tumour cells, and microRNAs, have the potential to improve candidate selection, detect minimal residual disease, and enable earlier, biology-driven identification of recurrence, thereby supporting a more personalised approach to LT in primary liver cancers.