Background: The relevant number of patients with hepatocellular carcinoma (HCC) beyond the Milan criteria has undergone living donor liver transplantation (LDLT). However, the prognostic factors for these patients with advanced HCC are not well established.

Methods: From March 2005 to May 2013, 280 patients with HCC underwent LDLT in the National Cancer Center. Among these, patients beyond the Milan criteria were retrospectively enrolled. We analyzed the prognostic significance of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT) for selecting appropriate candidates.

Results: Among total 280 patients, 147 patients (52.5%) were confirmed to have HCC beyond the Milan criteria using pathological reports. The patients who met and exceeded the Milan criteria had 5-year overall survival (OS) rates of 87.2% and 64.6%, respectively, (p < 0.001). In multivariable analysis for OS and DFS in patients beyond the Milan criteria, PET/CT positivity [hazard ratio (HR) 2.714, p = 0.013 for OS; HR 3.803, p < 0.001 for DFS], total tumor size over 10 cm (HR 2.333, p = 0.035 for OS; HR 3.334, p = 0.001 for DFS), and microvascular invasion (HR 2.917, p = 0.025 for DFS) were significant prognostic factors. In particular, patients beyond the Milan criteria with a PET/CT-negative status and total tumor size < 10 cm showed similar OS and DFS in comparison with those within the Milan criteria.

Conclusions: A PET/CT status in LDLT is a useful marker to predict survival of patients with advanced HCC.

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