Multifaceted role of histopathology in liver transplantation for hepatocellular carcinoma: A narrative review towards precision prognosis.

Hepatocellular carcinoma is a leading cause of cancer mortality globally. Liver transplantation is considered the best curative treatment for selected patients, as it removes the tumor and restores hepatic function. However, organ scarcity requires precise prognostic stratification. Histopathology is the essential bridge between morphology and biology, offering unique insights into tumor aggressiveness that imaging cannot capture. Öztürk et al recently published a study in the World Journal of Transplantation, analyzing a large United States transplant cohort analysis, which reveals clear differences in the risk profiles of macrovascular invasion and microvascular invasion. A central prognostic factor is macrovascular invasion. Macrovascular invasion indicates a poor prognosis, whereas microvascular invasion, detectable only histologically, defines an intermediate risk, highlighting the need for meticulous and standardized pathological examination. Prognostic accuracy is further refined by factors such as histological grading and specific subtypes (e.g., macrotrabecular-massive). Histopathological data guide clinical decision-making throughout the transplant process, from candidate selection to individualized surveillance. The incorporation of microvascular invasion or poor differentiation into predictive models improves patient management. In the future, digital pathology and artificial intelligence will automate the detection of prognostic markers, while molecular profiling will deepen our understanding of tumors at the morpho-molecular level. Within this integrated framework, histopathology has evolved into a dynamic science that is essential for the implementation of precision medicine for liver transplantation in cases of hepatocellular carcinoma. The liver explant has become a valuable repository of biological information that informs risk, guides therapy, and expands the field of transplant oncology.