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Beyond the Milan criteria: UCSF and extended rules for liver transplant | CION Cancer Clinics
Being outside the Milan criteria does not always rule out a liver transplant. Several later rules, including the UCSF criteria, allow a little more tumour, and some people can be brought within limits by treating the cancer first. This page explains how these extended criteria work, how transplant teams in India use them, and who they still do not suit. At CION Cancer Clinics, a multidisciplinary tumour board weighs your liver function and your scans before recommending any treatment.
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Medically reviewed by Dr. Muralidhar MuddusettyConsultant Surgical Oncologist · MBBS (AIIMS), MS (Surgery, AIIMS), DNB (Surgical Oncology), MRCS (Edinburgh) · last reviewed October 2026, next review due October 2027
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On this page
- Can I still have a transplant if my liver cancer is outside Milan?
- What are the UCSF and other extended criteria?
- How does a team decide whether to go beyond Milan?
- Which words will the transplant team use?
- When will extended criteria not help?
- What this page cannot tell you
- Common questions about criteria beyond Milan
The short answer
Can I still have a transplant if my liver cancer is outside Milan?
Sometimes, yes. The Milan criteria are the oldest and strictest rule for offering a liver transplant to someone with hepatocellular carcinoma (HCC, cancer that starts in the liver cells). Several later rules, including the UCSF criteria, allow a little more tumour. Being outside Milan narrows your options. It does not close them on its own.
Why there is more than one rule
Every rule is trying to answer the same question: is this cancer likely to stay away once the old liver is replaced? Milan answered it by counting tumours and measuring them. Later groups found that some people just over those limits did nearly as well, so they widened the limits carefully. Others added a blood test or the way the tumour behaved over time.
This page is about primary liver cancer
These rules apply to HCC that began in the liver. Cancer that spread to the liver from the bowel, breast or elsewhere is not judged this way. If that is your situation, start with the Milan criteria explained page only for background, and ask your oncologist which page fits.
A criterion is a guide used by the transplant team. It is not a verdict on you.The main families
What are the UCSF and other extended criteria?
You may hear several names. They fall into four broad groups, and each one widens Milan in a different way.
UCSF criteria
Named after the University of California, San Francisco. It allows a somewhat larger single tumour, or up to three tumours that are each a little larger than Milan permits, with a limit on their combined size. It is the most widely quoted step beyond Milan.
Size and number combined
Some rules, such as the "up-to-seven" idea, add the size of the largest tumour to the number of tumours and set a ceiling on the total. A few bigger tumours, or several small ones, can both fit.
Rules that add a blood marker
Some newer models look at AFP (alpha-fetoprotein, a protein some liver cancers release into the blood) alongside size. A low and steady AFP can support a larger tumour. A very high AFP can count against a small one.
Why it helps
- It hints at how the cancer behaves, not only how big it is
- It can be repeated after treatment to see the response
Living donor criteria from Asia
Transplant centres in Japan, Korea and China built their own wider rules for living donor transplant, often using tumour size, number, AFP and other markers together. Indian centres draw on these as well as on Milan and UCSF.
Not sure whether this applies to you?
Ask an oncologistHow the decision is made
How does a team decide whether to go beyond Milan?
A fresh, good-quality scan
The team needs a recent triple-phase CT or MRI that counts every tumour and measures it, and checks the large blood vessels and the rest of the body. CION arranges these scans through diagnostic partners when they are needed.
The tumour board reviews it
Liver surgeons, oncologists and radiologists look at the size, the number, the AFP level and whether the cancer has reached the portal vein. Cancer growing into major vessels usually rules a transplant out under any criterion.
A trial of treatment
Many teams treat the cancer first with TACE or ablation and watch what happens. This is called downstaging. A tumour that shrinks and stays quiet tells the team far more than a single measurement.
The transplant centre decides
The final yes or no belongs to the licensed transplant centre that would carry out the operation. CION's team helps you prepare the reports and understand the answer, but does not decide eligibility.
On your report
Which words will the transplant team use?
- Within Milan
- The cancer fits the original, strict rule. This is the group most transplant centres everywhere will consider.
- Within UCSF
- The cancer is outside Milan but inside the wider UCSF limits. Many centres will still consider a transplant.
- Downstaged
- The cancer was too large at first, was treated, and now fits a rule. Teams usually want it to stay that way for a while before going ahead.
- Vascular invasion
- The cancer has grown into a blood vessel such as the portal vein. This is the single biggest reason a transplant is not offered.
- AFP response
- How the AFP blood level changed after treatment. A falling AFP is reassuring. A rising one is a warning sign the team will discuss with you.
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Did you know
In India most liver transplants use part of a liver from a living family donor, not an organ from the shared waiting list. That is one reason some Indian centres will look beyond Milan. It also means the donor's own safety weighs heavily in every decision.
Who this does not suit
When will extended criteria not help?
Wider rules still have firm edges. Cancer that has spread outside the liver, to the lungs, bones or lymph nodes, is not treated with a transplant under any criterion. Cancer growing into the main portal vein or the large veins near the heart is usually excluded too.
When the cancer behaves aggressively
A tumour that keeps growing during treatment, or an AFP that keeps rising, suggests the cancer is likely to come back in the new liver. In that situation a transplant may expose a donor to risk without a lasting benefit for you. Teams will say so honestly.
When the body cannot take the operation
A transplant is a very large operation. Serious heart or lung disease, uncontrolled infection or a recent other cancer can rule it out, whatever the tumour looks like. The who is not eligible page goes through these in more detail.
When other treatment fits better
Some people outside Milan do better with resection, TACE, radiation or medicines such as immunotherapy. Being turned down for a transplant does not mean being turned down for treatment.
Being straight with you
What this page cannot tell you
It cannot tell you whether your own scan falls inside any of these rules. Measuring liver tumours is harder than it sounds. Two radiologists can measure the same tumour slightly differently, and a scan that is a few weeks old may already be out of date. Only a team looking at your images together can place you.
It cannot predict how you will do
The criteria describe how groups of patients have done. They say nothing certain about one person, and this page gives no prognosis. Results also differ between centres and between living and deceased donor transplants.
It cannot tell you which centre will accept you
Each licensed transplant centre in India sets its own limits within national rules, and those limits change. Ask the centre directly, and ask which rule they use. If you are weighing options, a CION second opinion can help you understand the full range, including treatments other than a transplant.
Bring every scan, every report and every AFP result you have, in date order. It saves weeks.Questions we are asked
Common questions about criteria beyond Milan
Is UCSF better than Milan?
Not better, just wider. Milan is stricter, so people inside it tend to have the lowest chance of the cancer coming back. UCSF accepts a little more tumour, and studies suggest people just outside Milan but inside UCSF can still do well. Which rule a centre uses is its own decision.
My report says outside Milan. Does that mean no transplant?
Not always. Some centres use UCSF or other extended rules, and some people can be brought within limits through downstaging treatment. Ask the team which rule they applied, whether downstaging is possible, and what other treatments suit you if a transplant does not.
What is downstaging?
Treating the cancer first, often with TACE, ablation or radiation, to shrink it until it fits a transplant rule. The team then watches for a period to make sure it stays controlled. It does not work for everyone, and how the tumour responds is itself useful information.
Why does the AFP level matter so much?
AFP is a protein some liver cancers release into the blood. A very high or rising level can mean the cancer is more aggressive than its size suggests. Several newer transplant rules use AFP alongside size, so your team will usually check it more than once.
Do Indian centres follow these criteria?
Most use Milan and UCSF as a starting point, and many also draw on rules developed for living donor transplant in Asia. There is no single national rule for living donor cases, so limits vary from centre to centre. Always ask which rule a centre uses.
Can CION help me get a place on the waiting list?
No. Nobody outside the official system can influence waiting-list priority or organ allocation. CION can review your case, explain your options, help gather the reports a transplant centre will ask for, and coordinate your care with that centre. Allocation follows the rules of the state programme.
Does a living donor change which rule applies?
It can. Because the organ is not taken from the shared list, some centres accept slightly more tumour for a living donor transplant. They still weigh the risk to a healthy donor very carefully, and will not proceed if the chance of the cancer returning seems high.
What should I bring to a transplant discussion?
Every scan on a disc or link, every radiology report, all AFP results with dates, your liver blood tests, and a list of treatments you have had. Call the CION helpline if you are not sure where to start, and someone will help you put it in order.
Your Specialists
Meet CION's liver cancer specialists. Bring your scan reports and liver blood tests.
Our medical and surgical oncologists plan liver cancer care together, weighing the tumour and how well your liver works before choosing surgery, a liver-directed procedure or medicines.
Medical Oncologist
Dr. C. Raghavendra Reddy
MBBS(Gold Medal), DNB(General Medicine), DM(Medical Oncology)(Gold Medal)
Medical Oncologist
Dr. Bharati Devi Gorantla
MBBS, MD(General Medicine), DM(Medical Oncology)(Adyar,Chennai), ECMO, MRCP SCE(UK)
Medical Oncologist
Dr. Owais Mohammed
MBBS, MD (General Medicine), DrNB (Medical Oncology), ECMO, MRCP SCE (Medical Oncology) (UK)
Medical Oncologist
Medical Oncologist
Surgical Oncologist
Dr. Muralidhar Muddusetty
MBBS (AIIMS), MS (Surgery) (AIIMS), DNB (Surgical Oncology), MRCS (Edinburgh)
Surgical Oncologist
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Sources
- EASL — EASL Clinical Practice Guidelines: management of hepatocellular carcinoma
- MedlinePlus — Liver Transplantation
- American Cancer Society — Surgery for Liver Cancer
- NIDDK — Liver Transplant - NIDDK
This page is general information, not a prescription. Do not change or stop any treatment based on what you read here. If anything is worrying you, contact your own treating team — or call our helpline and we will help you reach the right specialist.
Keep reading
Related pages
The Milan criteria explainedThe original rule, in plain words, before the extensionsDownstaging to become transplant-eligibleHow treatment can bring a larger cancer within limitsWho is not eligible for a liver transplantThe firm edges no criterion movesLiving donor liver transplant in IndiaWhy living donation changes the picture here
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