Liver transplantation for hepatocellular carcinoma (HCC) in North America has undergone substantial change since its inception. Transplantation for large tumors led to near universal tumor recurrence and despite its theoretical benefit, complete liver replacement for primary hepatic malignancy was all but abandoned outside of clinical trials. With the publication of the Milan criteria interest was renewed and results of transplant for HCC began to mirror those for non-malignant indications. The adoption of MELD-based allocation led to a substantial increase in the number of transplants for HCC as MELD priority points were given to patients who met the restrictive criteria. As results of transplantation improved, several groups have pushed the boundaries of Milan and found similar results. To further possibility of transplantation for patients with tumors outside of criteria, locoregional therapies have been utilized to downstage these tumors. As the number of patients awaiting a deceased donor allograft continues to increase while the number of available deceased donor organs remains relatively constant, the roles of living donor transplantation, adjuvant, and neoadjuvant therapy will continue to evolve.