Medical Oncologist
CION Cancer Clinics
The Milan criteria for liver transplant in liver cancer, explained | CION Cancer Clinics
The Milan criteria are limits on the size and number of liver cancer tumours that transplant teams use to decide who is likely to benefit from a new liver. They allow one small tumour or a few very small ones, with no spread into blood vessels or outside the liver. This page explains the limits in plain words, how scans are read against them, and what happens if you fall outside. 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
- What are the Milan criteria?
- What exactly do the Milan criteria allow?
- What does the transplant team actually count?
- How is it decided whether you are within Milan?
- What families often get wrong about the Milan criteria
- Who do the Milan criteria not apply to?
- What this page cannot tell you
- Common questions about the Milan criteria
The short answer
What are the Milan criteria?
The Milan criteria are a set of limits on the size and number of liver tumours that transplant teams use to decide who is likely to do well after a liver transplant for cancer. If the cancer sits within these limits, the chance of it coming back in the new liver is low enough for a transplant to make sense.
Why a rule is needed at all
Donor livers are scarce, and a transplant is major surgery followed by lifelong medicines. A transplant only helps if the cancer has not already seeded outside the liver. Doctors cannot see single cancer cells on a scan, so they use tumour size and number as a stand-in. Smaller and fewer tumours are less likely to have spread unseen.
Which cancer this applies to
The Milan criteria were written for hepatocellular carcinoma (HCC), the cancer that starts in the liver cells, usually in a liver with cirrhosis. They do not apply to cancer that spread to the liver from the bowel, breast or elsewhere. For bile duct cancer, see transplant for perihilar bile duct cancer.
Being within Milan makes you a candidate to be assessed. It does not by itself mean a transplant will happen.The limits, in plain words
What exactly do the Milan criteria allow?
- One tumour
- A single tumour no larger than five centimetres across, roughly the size of a lemon.
- Or a few small tumours
- Up to three tumours, and none of them larger than three centimetres, roughly the size of a large grape or a walnut.
- No spread into blood vessels
- The scan must show no cancer growing into the main blood vessels of the liver, such as the portal vein, which carries blood into the liver.
- No spread outside the liver
- No cancer in the lymph nodes, lungs, bones or anywhere else beyond the liver.
- Within Milan
- The phrase your doctor will use when all of the above are true.
- Beyond Milan
- When any one of them is not met. Some centres still consider these people under wider rules.
Not sure whether this applies to you?
Ask an oncologistReading the scan
What does the transplant team actually count?
The rule sounds simple. Applying it to a real scan takes judgement, and that is where questions arise.
Only tumours that look like cancer
A cirrhotic liver is full of nodules. The radiologist counts only the ones with the typical pattern of HCC on a contrast CT or MRI, often reported with a LI-RADS score, a grading of how likely a spot is to be cancer.
The widest measurement
Each tumour is measured across its longest side on the most recent good-quality scan. Two radiologists can measure the same spot slightly differently, so borderline cases are often reviewed again.
Treated tumours
If a tumour has been treated with TACE or ablation, teams look at how much living tumour remains. Some count only the part that still lights up on the scan.
The AFP blood test
The original rule did not use AFP, a protein some liver cancers release into the blood. Many teams now look at it too, because a very high or rising level can suggest a more aggressive cancer.
From scan to decision
How is it decided whether you are within Milan?
A recent, good-quality scan
A triple-phase CT or a contrast MRI of the liver, plus a chest CT to look for spread. CION arranges these through accredited diagnostic partners if they have not been done.
A tumour board review
Oncologists, surgeons and radiologists look at the scans together, count the tumours, measure them and check the blood vessels. They also look at liver function and your general fitness.
Treatment while you wait, if needed
If you are within Milan, treatment such as TACE or ablation may be used to keep the cancer from growing during assessment. This is called bridging therapy.
Referral to a licensed transplant centre
The transplant centre makes the final decision after its own assessment. Your team will tell you where the operation takes place.
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Commonly believed
What families often get wrong about the Milan criteria
"We are beyond Milan, so nothing can be done."
Being beyond Milan closes one door, not all of them. Surgery, ablation, TACE, radiation and medicines may still help. Some people can also be brought back within the limits by treatment, which is called downstaging.
"Within Milan means the transplant will definitely work."
It means the odds are good enough to go ahead. Cancer can still come back, because some cells may have escaped before the operation. Regular scans after a transplant are part of the plan.
"The criteria are about how sick the liver is."
They are about the cancer only. How well the liver works is judged separately, with scores such as Child-Pugh and MELD. Someone can be within Milan with a fairly healthy liver, or with a very weak one.
"A private payment can get round the rules."
It cannot, and nobody should offer that. Deceased donor livers are shared through government programmes such as Jeevandan, and buying or selling organs is illegal in India.
Not everyone
Who do the Milan criteria not apply to?
They do not apply to cancer that began somewhere else and spread to the liver, to bile duct cancer in most cases, or to children with hepatoblastoma, who are assessed under different rules. They also say nothing about whether surgery to remove part of the liver is possible. That decision depends on where the tumour sits and how much healthy liver would be left.
When Milan is not the only rule
Many transplant centres, particularly those doing living donor transplants, use wider criteria. Some look at total tumour size, the AFP level, or how the cancer responded to earlier treatment. The page on extended criteria explains these. Wider rules can help more people, but the risk of the cancer returning is higher, and the donor's risk stays the same either way. Families deserve a frank conversation about that balance.
Being straight with you
What this page cannot tell you
It cannot tell you whether you or your parent are within Milan. That needs the actual images, read by a radiologist who knows the liver, and a team that can compare old and new scans. A report that lists sizes is a starting point, not the final word.
It cannot predict how one person will do
The criteria describe groups of patients, not individuals. Your transplant team will talk about your own situation, including your liver function, your fitness and the donor options in your family.
The rules change
Allocation rules for deceased donor livers in Telangana are set by Jeevandan and national bodies, and they change. As of 2026, check the current position with the transplant centre directly. CION cannot affect anyone's place on a waiting list.
Questions we are asked
Common questions about the Milan criteria
Why are they called the Milan criteria?
They come from a study of liver transplant for liver cancer carried out by surgeons in Milan, Italy, in the nineteen-nineties. The study showed that people with small, few tumours did much better after transplant than those with larger ones. The rule has been used worldwide ever since.
My report says one tumour just over the limit. Is that the end?
Not necessarily. Measurements vary a little between scans and readers, so borderline cases are usually re-reviewed. Treatment such as TACE or ablation may shrink the tumour, and some centres use wider criteria. Ask the team to explain exactly which limit was crossed and what options remain.
Do small spots called dysplastic nodules count?
Usually not. Nodules that do not show the typical pattern of cancer on a contrast scan are generally not counted, though they are watched closely. Spots reported as probably cancer may be discussed case by case. The radiologist and the transplant team decide together what counts.
Can treatment bring me back within Milan?
Sometimes. Treatments such as TACE, TARE or ablation can shrink tumours enough to fall within the limits. This is called downstaging. Teams usually want the cancer to stay controlled for a period after downstaging before a transplant goes ahead, to make sure it is not aggressive.
Do the criteria matter for a living donor transplant?
Yes, though some centres use wider limits for living donor transplants because the liver is not taken from a shared list. The donor still faces major surgery, so teams want a reasonable chance that the cancer will not return before they accept that risk for a healthy person.
Does liver function decide if I am within Milan?
No. Milan describes only the cancer. Liver function is measured separately with Child-Pugh and MELD scores, which look at bilirubin, albumin, clotting and other signs. Both matter when a team decides whether a transplant, surgery or another treatment fits best.
What happens if the cancer grows while I wait?
If tumours grow beyond the limits or spread into a blood vessel, a person may be taken off the waiting list. This is why bridging treatment and regular scans are used during the wait. If it happens, other treatments are still available to control the cancer.
How can CION help with this question?
CION's tumour board can review your scans, explain where you stand against Milan and other criteria, and plan treatment to control the cancer meanwhile. If a transplant is worth pursuing, the team refers you to a licensed transplant centre. Call the helpline to arrange a review.
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
- American Cancer Society — Surgery for Liver Cancer
- American College of Radiology — ACR Liver Imaging Reporting & Data System (LI-RADS®)
- 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
Beyond Milan: UCSF and extended criteriaThe wider rules some centres useDownstaging to become transplant-eligibleIf the tumour is currently too largeWhy transplant can treat both the cancer and the cirrhosisWhy the limits exist in the first placeChild-Pugh A, B and C explainedThe separate score for liver function
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Not sure whether your scan is within Milan?
Share the scans and reports, and our tumour board will explain where things stand and what options remain either way. One helpline serves every CION centre.