Milan-out Criteria and Worse Intention-to-Treat Outcome Postliver Transplantation Background. Milan criteria are widely used for liver transplantation selection in hepatocellular carcinoma but have been recognized to be too restrictive. Milan-out criteria are increasingly being adopted. Our aim was to analyze if liver transplantation waitlisted Milan-out hepatocellular carcinoma patients have different outcome than Milan patients. Methods. Retrospective study including all consecutive patients with hepatocellular carcinoma admitted in the waiting list for liver transplantation between January 2012 and January 2015. We included 177 patients, 146 of which eventually transplanted. Downstaging was achieved in the Milan-out cases (n = 29) before waitlisting. Results. From diagnosis to last follow-up, 29% patients died. Survival at 1 and 5 years from diagnosis was 93% and 75%, respectively in the within Milan group compared with 91% and 61% in the Milan-out group (P = 0.03). Treatment failure occurred in 20% of cases due to tumor progression in the waiting list (44%), death on the waiting list (20%), and hepatocellular carcinoma recurrence postliver transplantation (9%). Milan-out criteria was the only variable predictive of treatment failure remaining in the multivariate analysis with a hazard ratio (HR) of 1.7 (HR, 1.7; 95% confidence interval, 1.34-4.55; P = 0.010) and HR of 1.43 (1.23-6.5) in the hepatocellular carcinoma recurrence. Conclusions. Milan-out criteria are associated with a higher intention-to-treat liver transplantation failure from time of inclusion in the waiting list. However, survival rates are still >50% at 5 years of follow-up. Published online 18 September, 2019. Received 25 June 2019. Revision received 19 July 2019. Accepted 23 July 2019. M.B. and A.R. involved in study concept and design. J.H. and F.S.J. involved in acquisition of data. J.H., T.D.M., and M.B. involved in statistical analysis. J.H., T.D.M., and M.B. involved in analysis and interpretation of data. M.B. and J.H. involved in drafting of the manuscript. T.D.M., G.S., C.V., F.S.J., A.R., and M.B. involved in critical revision of the manuscript. This work was supported by a grant from Ciberehd (Instituto de Salud Carlos III, Madrid, Spain). The authors declare no conflicts of interest. Correspondence: Marina Berenguer, MD, PhD, Hospital Universitario y Politécnico La Fe, Avda. Fernando Abril Martorell 106, 46026 Valencia Spain. (marina.berenguer@uv.es). This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. © 2019 The Authors. Published by Wolters Kluwer Health, Inc.