Despite improvements in therapeutic modalities over the past decade hepatocellular carcinoma (HCC) remains the second leading cause of cancer related deaths accounting for approximately 700,000 deaths worldwide each year [1]. HCC is frequently multifocal and arises in setting of cirrhosis (>80%) [2], hence surgical resection of HCC with curative intent is only feasible in 20-30% of patients at time of diagnosis [3]. We have known for years that liver transplantation (LT) is the gold standard for HCC therapy in the setting of significant liver disease given its oncologic advantage of replacing the organ harboring malignancy all while reversing the physiologic liver dysfunction. In 1996 Mazzafero et al. demonstrated that by limiting LT to HCC patients with a single tumor of ≤ 5 cm, or up to 3 tumor nodules ≤ 3 cm, excellent outcomes could be achieved giving rise to the influential Milan Criteria [4]. In many parts of the world, great efforts have been made to push the envelope, transplanting patients with tumors well outside Milan; yet in the United States, we remain stagnant in our behavior. Yao et al. created what we now know as the UCSF criteria which includes a single tumor ≤ 6.5 cm, or up to three 3 tumor nodules ≤ 4.5 cm with total tumor diameter ≤ 8 cm [5].