Background: Liver transplantation achieves better results when hepatocellular carcinoma fits the Milan criteria. This study investigated predictors of recurrent hepatocellular carcinoma exceeding the Milan criteria. Methods: Among 285 patients with hepatocellular carcinoma fitting the Milan criteria who underwent curative resection, 143 patients suffered initial recurrence (92 had tumors fitting the criteria) and 71 patients suffered a second recurrence (40 conforming tumors). Results: Survival after hepatectomy was significantly worse when initial recurrence was nonconforming. Similarly, survival after initial recurrence was significantly worse when the second recurrence was nonconforming. A preoperative increase of protein induced by vitamin K absence/antagonist II, a tumor diameter of 3 cm or greater, age of 65 years or younger, and intraoperative blood transfusion increased the risk of nonconforming initial recurrence. Conclusions: Liver transplantation should be considered initially for younger patients with hepatocellular carcinoma fitting the Milan criteria, larger tumors, and an increase of protein induced by vitamin K absence/antagonist II.
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