Downstaging hepatocellular carcinoma (HCC) prior to liver transplantation (LT) is an acceptable means by which patients who present beyond early-stage criteria could be offered a curative therapy. Downstaging is typically achieved through treatment with locoregional therapies, which both decrease viable tumor burden and also allow for assessment of tumor biology. The current evidence supports patients can achieve substantial benefits with downstaging, but caution must be taken in patient selection to avoid pre- and post-liver transplantation (LT) harms.