The principal advancements in the treatment of hepatocellular carcinoma (HCC) 
are the use of new systemic treatments, such as lenvatinib in first-line 
treatment and regorafenib, cabozantinib, and ramucirumab in second-line 
treatment, because of their benefits in terms of overall survival. In addition, 
nivolumab as a second-line agent was approved by the US Food and Drug 
Administration in 2017 based on improved radiological response data. Physicians 
and patients alike will greatly benefit from this expanded arsenal of treatments 
once all these new drugs for the treatment of HCC finally become available. 
Unfortunately, in our review of the available data, we found a conspicuous lack 
of approved systemic treatments for HCC in the distinct setting of after liver 
transplantation (LT). Careful evaluation of the clinical trials for approved 
systemic treatments of HCC is crucial when considering the best options for 
those with HCC recurrence after LT. Although several first-line or second-line 
treatments have been shown to be effective for HCC, each of these trials was 
composed of its own specific populations, and those with HCC recurrence after LT 
were excluded. We have also summarized from a critical and clinical point of 
view the issues involved in the management of patients who are candidates for 
systemic treatment in this era of multiple drugs for the same indication.