AUTHOR=Jo Younggoun , Park Yunchul , Lee Ho-Kyun , Lee Sola , Jung Hong-Sung , Choi Soo Jin Na , Kim Hyo-Sin 
  
TITLE=Post-transplant oncologic outcomes after locoregional downstaging before living donor liver transplantation for hepatocellular carcinoma beyond Milan criteria: a systematic review and meta-analysis of selected cohorts
  
JOURNAL=Transplant International
  
VOLUME=Volume 39 - 2026
  
YEAR=2026
  
URL=https://www.frontierspartnerships.org/journals/transplant-international/articles/10.3389/ti.2026.17284
  
DOI=10.3389/ti.2026.17284
  
ISSN=1432-2277
  
ABSTRACT=Downstaging of hepatocellular carcinoma (HCC) before liver transplantation is established mainly in the deceased donor setting, and outcomes before living donor liver transplantation (LDLT) remain unclear. We searched PubMed and Embase through April 2026 for studies reporting post-transplant outcomes in patients with HCC beyond Milan criteria who were downstaged before LDLT. A pre-specified primary analysis covered locoregional therapy targeting Milan or UCSF criteria. We pooled proportions using random-effects models and reconstructed patient-level survival from Kaplan-Meier curves. Seventeen studies with 511 downstaged LDLT recipients were included. In the primary cohort, recurrence was 22.1% (95% CI 9.7–42.6) and 5-year overall survival 75.8% (61.8–85.8). Across all studies, recurrence was 25.0% (17.4–34.5), 5-year overall survival 75.0% (63.1–84.1), and downstaging success 47.5% (36.1–59.1); reconstructed 5-year overall and recurrence-free survival were 75.7% and 75.6%. These estimates describe patients who achieved downstaging—fewer than half of those who attempted it—and then reached transplant. They do not measure the benefit of downstaging itself. The evidence remains retrospective and mostly Asian, with wide variation between studies. Prospective intention-to-treat studies are needed.