{"id":3008,"date":"2026-09-15T14:14:35","date_gmt":"2026-09-15T14:14:35","guid":{"rendered":"https:\/\/bookinghospital.org\/?p=3008"},"modified":"2026-10-10T08:44:29","modified_gmt":"2026-10-10T08:44:29","slug":"liver-transplant-for-liver-cancer","status":"publish","type":"post","link":"https:\/\/bookinghospital.org\/pl\/liver-transplant-for-liver-cancer\/","title":{"rendered":"Liver Cancer and Transplant: Milan Criteria and Beyond"},"content":{"rendered":"<div data-elementor-type=\"wp-post\" data-elementor-id=\"3008\" class=\"elementor elementor-3008\">\n\t\t\t\t<div class=\"elementor-element elementor-element-d16e186 e-con-full e-flex e-con e-parent\" data-id=\"d16e186\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-043d061 elementor-widget elementor-widget-html\" data-id=\"043d061\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div id=\"bh\">\n\n<section class=\"hero\">\n  <div class=\"in\">\n    <p class=\"eyebrow\">Liver transplantation \u00b7 Liver cancer<\/p>\n    <h1>Told your liver cancer is too advanced for a transplant?<\/h1>\n    <p class=\"lead\">For some patients with liver cancer, a transplant is the treatment most\n       likely to cure it. The rules on who qualifies are stricter than for other patients \u2014\n       but they are not a single yes-or-no line. Here is what the criteria and the trials\n       actually say.<\/p>\n    <p class=\"meta\">Based on international guidelines, consensus reports and clinical\n       trials<\/p>\n  <\/div>\n<\/section>\n\n<section class=\"wrap\">\n\n  <div class=\"ozet\">\n    <h2>The short answer<\/h2>\n    <ul>\n      <li>A transplant can cure some patients with hepatocellular carcinoma (HCC), because it\n          removes the <b>tumour and the diseased liver together<\/b>.<\/li>\n      <li>The <b>Milan criteria<\/b> are the standard: one tumour up to 5 cm, or up to three\n          tumours each up to 3 cm.<\/li>\n      <li><b>Beyond Milan is not automatically no.<\/b> Expanded criteria exist, and tumours can\n          sometimes be shrunk back within limits \u2014 known as <b>downstaging<\/b>.<\/li>\n      <li>Tumour size is not the whole story. The blood marker <b>AFP<\/b> predicts whether the\n          cancer will come back almost as strongly.<\/li>\n      <li>What usually rules transplant out: <b>spread into major blood vessels or outside\n          the liver<\/b>.<\/li>\n    <\/ul>\n  <\/div>\n\n  <h2>Why a transplant, and why the rules are strict<\/h2>\n\n  <p>Most liver cancer grows in a liver already damaged by cirrhosis. Removing only the tumour\n     leaves the diseased liver behind, where new tumours can form. A transplant removes both.<\/p>\n\n  <p>The difficulty is that cancer cells may already have escaped the liver before the\n     operation. After a transplant, the medicines that prevent rejection weaken the immune\n     system \u2014 and any cancer left in the body can grow faster. So teams select patients whose\n     cancer is <b>likely to be confined to the liver<\/b>.<\/p>\n\n  <h2>The Milan criteria<\/h2>\n\n  <p>In 1996, a team in Milan showed that carefully selected patients did well after\n     transplantation. In their original study of 48 patients, <b>75% were alive four years\n     later<\/b>. Their selection rules became the international standard:<\/p>\n\n  <div class=\"tblwrap\">\n    <table>\n      <thead>\n        <tr><th>Milan criteria<\/th><th><\/th><\/tr>\n      <\/thead>\n      <tbody>\n        <tr><td><b>One tumour<\/b><\/td><td>Up to 5 cm<\/td><\/tr>\n        <tr><td><b>Or up to three tumours<\/b><\/td><td>Each up to 3 cm<\/td><\/tr>\n        <tr><td><b>And<\/b><\/td><td>No invasion of blood vessels, no spread outside the liver<\/td><\/tr>\n      <\/tbody>\n    <\/table>\n  <\/div>\n\n  <p>The current European guideline still uses Milan as the reference standard.<\/p>\n\n  <h2>Beyond Milan: the expanded criteria<\/h2>\n\n  <p>Milan was designed to be safe, not to be the limit of what is possible. Several teams\n     have since shown that some patients with larger or more numerous tumours also do well:<\/p>\n\n  <div class=\"tblwrap\">\n    <table>\n      <thead>\n        <tr><th>Criteria<\/th><th>Limits<\/th><th>What it adds<\/th><\/tr>\n      <\/thead>\n      <tbody>\n        <tr><td><b>UCSF<\/b> (2001)<\/td><td>One tumour under 6.5 cm, or up to three tumours with the largest under 4.5 cm and a total under 8 cm<\/td><td>Larger tumour size<\/td><\/tr>\n        <tr><td><b>Up-to-seven<\/b> (2009)<\/td><td>Size of the largest tumour in cm + number of tumours = 7 or less<\/td><td>Among patients beyond Milan but within up-to-seven, without microscopic vessel invasion: <b>71.2%<\/b> alive at 5 years<\/td><\/tr>\n        <tr><td><b>AFP model<\/b> (2012)<\/td><td>Combines tumour size, number and AFP level into a score<\/td><td>Tumour biology, not just size<\/td><\/tr>\n        <tr><td><b>Malatya<\/b> (Turkey, 2020)<\/td><td>Largest tumour 6 cm or less, AFP 200 ng\/ml or less, GGT 104 IU\/L or less, and a well or moderately differentiated tumour<\/td><td>Blood markers and tumour grade<\/td><\/tr>\n      <\/tbody>\n    <\/table>\n  <\/div>\n\n  <p>Different centres use different expanded criteria. Being outside the criteria used at one\n     centre does not always mean being outside the criteria used at another.<\/p>\n\n  <h2>AFP: why a blood test matters as much as a scan<\/h2>\n\n  <p>Alpha-fetoprotein (<b>AFP<\/b>) is a protein many liver cancers release into the blood. A\n     high AFP often signals a more aggressive tumour.<\/p>\n\n  <p>In the study that developed the AFP model, patients with a score <b>above 2<\/b> had a\n     <b>50.6%<\/b> risk of the cancer returning within five years. Patients with a score of\n     <b>2 or less<\/b> had an <b>8.8%<\/b> risk.<\/p>\n\n  <div class=\"box\">\n    <span class=\"etiket\">The AFP line in the European guideline<\/span>\n    <p>Patients with an AFP <b>above 1,000 ng\/ml<\/b> should not be considered for a transplant \u2014\n      unless treatment brings the level down and keeps it down.<\/p>\n  <\/div>\n\n  <h2>Downstaging: shrinking the cancer first<\/h2>\n\n  <p>If a tumour is beyond the criteria, treatments applied directly to the liver \u2014 such as\n     chemoembolisation or ablation \u2014 can sometimes shrink it back within limits. This is called\n     <b>downstaging<\/b>.<\/p>\n\n  <ul>\n    <li>The European Society of Organ Transplantation recommends that <b>all patients beyond\n        transplant criteria, without spread outside the liver or invasion of major blood\n        vessels, should be considered for downstaging<\/b>.<\/li>\n    <li>Success is judged using established criteria that combine <b>tumour size and AFP<\/b>.<\/li>\n    <li>The response must <b>last over time<\/b> before transplantation \u2014 a tumour that shrinks\n        briefly and grows back is a warning sign.<\/li>\n  <\/ul>\n\n  <div class=\"soru\">\n    <h3>Does downstaging actually work?<\/h3>\n\n    <p>The XXL trial is the only randomised trial to test it. Patients whose cancer was beyond\n       Milan but was successfully and durably downstaged were assigned either to a transplant or\n       to continued non-transplant treatment.<\/p>\n\n    <div class=\"tblwrap\">\n      <table>\n        <thead>\n          <tr><th>At 5 years<\/th><th>Transplant<\/th><th>No transplant<\/th><\/tr>\n        <\/thead>\n        <tbody>\n          <tr><td>Alive<\/td><td><b>77.5%<\/b><\/td><td>31.2%<\/td><\/tr>\n          <tr><td>Alive and tumour-free<\/td><td><b>76.8%<\/b><\/td><td>18.3%<\/td><\/tr>\n        <\/tbody>\n      <\/table>\n    <\/div>\n\n    <p>The trial was small \u2014 45 patients \u2014 and closed early, so the results must be read with\n       caution. But the difference is large.<\/p>\n  <\/div>\n\n  <p>While waiting for a transplant, patients may also receive <b>bridging therapy<\/b> \u2014 the\n     same liver-directed treatments, used to keep the cancer under control. The European\n     consensus recommends considering it wherever feasible. Patients who have received\n     immunotherapy need a <b>washout period of at least four weeks<\/b> before transplantation.<\/p>\n\n  <h2>The living donor question<\/h2>\n\n  <p>With a living donor, the transplant can be <b>scheduled<\/b> \u2014 the patient does not wait on\n     a list while the cancer may grow. The international living donor guideline states that\n     patients with cancer beyond the Milan criteria <b>may benefit<\/b> from a living donor\n     transplant, but there is <b>no agreement on how far the limits can be extended<\/b>.<\/p>\n\n  <p>There is a second side to this decision. A living donor accepts a real risk\n     (<a href=\"\/pl\/living-liver-donor-real-risks-recovery-and-your-rights\/\">about 1 in 500<\/a>). The team has to weigh\n     that risk against the recipient's realistic chance of staying cancer-free. When the chance\n     of the cancer returning is very high, an honest team may advise against asking a family\n     member to take that risk.<\/p>\n\n  <h2>What usually rules a transplant out<\/h2>\n\n  <ul>\n    <li><b>Spread of the cancer outside the liver.<\/b><\/li>\n    <li><b>Invasion of major blood vessels<\/b> by the tumour.<\/li>\n    <li><b>AFP above 1,000 ng\/ml<\/b> that does not come down with treatment.<\/li>\n    <li>A cancer that keeps growing despite treatment.<\/li>\n  <\/ul>\n\n  <div class=\"box efsane\">\n    <span class=\"etiket\">The myth<\/span>\n    <p><b>\"Beyond Milan means no transplant.\"<\/b><\/p>\n    <p>For many patients, it does. But expanded criteria, downstaging and living donation mean\n      that some patients beyond Milan can still be considered. Ask whether your case has been\n      assessed against more than one set of criteria.<\/p>\n  <\/div>\n\n  <p>For the general conditions a transplant candidate must meet, see\n     <a href=\"https:\/\/bookinghospital.org\/pl\/liver-transplant-who-can-have-one\/\">who can have a liver transplant<\/a>.<\/p>\n\n  <div class=\"yazar\">\n    <div class=\"rozet\">MT<\/div>\n    <div>\n      <h3>Medically reviewed by <a href=\"https:\/\/bookinghospital.org\/pl\/murat-tuncer-md\/\" style=\"color:inherit\">Profesor dr Murat Tuncer<\/a><\/h3>\n      <p>Nephrologist and transplant physician. This guide was prepared by the BookingHospital medical\n        team from international guidelines, consensus reports and clinical trials.<\/p>\n    <\/div>\n  <\/div>\n\n  <div class=\"cta\">\n    <h2>Told your cancer is beyond the limits? Send us your scans<\/h2>\n    <p>Send your most recent CT or MRI report, your AFP results over time, and details of any\n       treatment you have had. We will tell you honestly whether an evaluation is worthwhile \u2014\n       including when the answer is no.<\/p>\n    <div class=\"btns\">\n      <a class=\"btn btn-1\" href=\"https:\/\/bookinghospital.org\/pl\/medyczny-turystyka\/\">Prze\u015blij swoje raporty medyczne<\/a>\n    <\/div>\n  <\/div>\n\n  <div class=\"uyari\">\n    <p><b>Wykluczenie odpowiedzialno\u015bci medycznej.<\/b> This article is general information based on published\n      guidelines and studies. It is not personal medical advice, it does not establish a\n      doctor\u2013patient relationship, and it cannot replace assessment by a multidisciplinary\n      liver cancer and transplant team. Criteria differ between centres and are applied to each\n      patient individually.<\/p>\n  <\/div>\n\n  <div class=\"kaynak\">\n    <h3>References<\/h3>\n    <ol>\n      <li>Mazzaferro V, Regalia E, Doci R, et al. Liver transplantation for the treatment of small\n        hepatocellular carcinomas in patients with cirrhosis. <i>N Engl J Med<\/i>\n        1996;334(11):693\u2013699.<\/li>\n      <li>Yao FY, Ferrell L, Bass NM, et al. Liver transplantation for hepatocellular carcinoma:\n        expansion of the tumor size limits does not adversely impact survival.\n        <i>Hepatology<\/i> 2001;33(6):1394\u20131403.<\/li>\n      <li>Mazzaferro V, Llovet JM, Miceli R, et al. Predicting survival after liver\n        transplantation in patients with hepatocellular carcinoma beyond the Milan criteria: a\n        retrospective, exploratory analysis. <i>Lancet Oncol<\/i> 2009;10(1):35\u201343.<\/li>\n      <li>Duvoux C, Roudot-Thoraval F, Decaens T, et al. Liver transplantation for hepatocellular\n        carcinoma: a model including \u03b1-fetoprotein improves the performance of Milan criteria.\n        <i>Gastroenterology<\/i> 2012;143(4):986\u2013994.<\/li>\n      <li>Ince V, Carr BI, Bag HG, et al. Liver transplant for large hepatocellular carcinoma in\n        Malatya: the role of gamma glutamyl transferase and alpha-fetoprotein, a retrospective\n        cohort study. <i>World J Gastrointest Surg<\/i> 2020;12(12):520\u2013533.<\/li>\n      <li>Mazzaferro V, Citterio D, Bhoori S, et al. Liver transplantation in hepatocellular\n        carcinoma after tumour downstaging (XXL): a randomised, controlled, phase 2b\/3 trial.\n        <i>Lancet Oncol<\/i> 2020;21(7):947\u2013956.<\/li>\n      <li>Claasen MPAW, Sneiders D, Rakk\u00e9 YS, et al. European Society of Organ Transplantation\n        (ESOT) consensus report on downstaging, bridging and immunotherapy in liver\n        transplantation for hepatocellular carcinoma. <i>Transpl Int<\/i> 2023;36:11648.<\/li>\n      <li>European Association for the Study of the Liver. EASL Clinical Practice Guidelines on\n        liver transplantation. <i>J Hepatol<\/i> 2024;81(6):1040\u20131086.<\/li>\n      <li>Miller CM, Quintini C, Dhawan A, et al. The International Liver Transplantation\n        Society Living Donor Liver Transplant Recipient Guideline. <i>Transplantation<\/i>\n        2017;101(5):938\u2013944.<\/li>\n    <\/ol>\n  <\/div>\n\n<\/section>\n\n<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>","protected":false},"excerpt":{"rendered":"<p>Liver transplantation \u00b7 Liver cancer Told your liver cancer is too advanced for a transplant? For some patients with liver cancer, a transplant is the treatment most likely to cure it. The rules on who qualifies are stricter than for other patients \u2014 but they are not a single yes-or-no line. Here is what the [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"elementor_header_footer","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"set","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"_joinchat":{"message_text":"Hello \ud83d\udc4b\n===\nConsidering a liver transplant in T\u00fcrkiye? Our transplant medical team can review your situation.\n===\nSend us a message with your country and whether you have a possible donor.","message_send":"Hello, I'd like information about liver transplant in T\u00fcrkiye. Country: \u2026 Possible donor: \u2026"},"footnotes":""},"categories":[17],"tags":[],"class_list":["post-3008","post","type-post","status-publish","format-standard","hentry","category-liver-transplant-guide"],"_links":{"self":[{"href":"https:\/\/bookinghospital.org\/pl\/wp-json\/wp\/v2\/posts\/3008","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/bookinghospital.org\/pl\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/bookinghospital.org\/pl\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/bookinghospital.org\/pl\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/bookinghospital.org\/pl\/wp-json\/wp\/v2\/comments?post=3008"}],"version-history":[{"count":4,"href":"https:\/\/bookinghospital.org\/pl\/wp-json\/wp\/v2\/posts\/3008\/revisions"}],"predecessor-version":[{"id":3013,"href":"https:\/\/bookinghospital.org\/pl\/wp-json\/wp\/v2\/posts\/3008\/revisions\/3013"}],"wp:attachment":[{"href":"https:\/\/bookinghospital.org\/pl\/wp-json\/wp\/v2\/media?parent=3008"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/bookinghospital.org\/pl\/wp-json\/wp\/v2\/categories?post=3008"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/bookinghospital.org\/pl\/wp-json\/wp\/v2\/tags?post=3008"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}