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Milan Criteria for Liver Transplantation in Hepatocellular Carcinoma

Milan criteria: a single HCC ≤5 cm, or up to 3 tumours each ≤3 cm, with no macrovascular invasion and no extrahepatic spread. Patients within Milan have about 75% 4-year survival after liver transplant, similar to non-HCC indications.

Number of tumours
Largest tumour diameter (cm or mm)
Macrovascular invasion (e.g. portal vein tumour thrombus) (yes/no, +1)
Extrahepatic spread (nodes or metastases) (yes/no, +1)

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Interpretation

Result	Meaning
Within	Single ≤5 cm or ≤3 tumours each ≤3 cm; no vascular invasion or extrahepatic disease
Outside	Consider downstaging or extended criteria (UCSF, Up-to-7) per centre policy

Formula

Within Milan = (1 tumour ≤5 cm OR 2–3 tumours each ≤3 cm) AND no macrovascular invasion AND no extrahepatic spread

Clinical pearls

Based on imaging; explant pathology often upstages.
Patients successfully downstaged into Milan (e.g. by TACE) can be transplanted with acceptable outcomes in many programmes.

Examples

milan criteria single 4.5 cm hcc no vascular invasion is hcc within milan: 3 lesions largest 3.5 cm milan 2 tumors 2.5 cm with portal vein tumor thrombus

FAQ

What are the Milan criteria?

One HCC up to 5 cm, or up to three HCCs none larger than 3 cm, without macrovascular invasion or spread outside the liver.

What happens if a patient is outside Milan?

Many centres attempt locoregional downstaging; some accept expanded criteria such as UCSF (single ≤6.5 cm, or ≤3 with largest ≤4.5 cm and total ≤8 cm).

Evidence

Mazzaferro V et al. Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis. N Engl J Med 1996;334:693–9.

Hepatology & GI · Reviewed 2026-10-14 · Methodology