BackgroundNew guidelines propose a minimum 5-year survival of 60% for hepatocellular carcinoma with living donor liver transplantation. This study evaluates the 5-year and 10-year survival following transplantation for expanded criteria for hepatocellular carcinoma. MethodsThis single-center retrospective cohort study included 208 patients who underwent living donor liver transplantation for an expanded criteria (largest tumor diameter ≤ 10cm, any tumor number, AFP < 1000ng/ml) and analyzed 5- and 10-year overall survival and recurrence risk. ResultsWith a median follow-up of 65.1 (19.1-80.2) months, the 5- and 10-year overall survival was 67% and 61% and recurrence risk was 20.5% and 22.5%. Largest tumor diameter >6cm (HR 3.7, CI 1.7-8.2, P =0.001) and AFP >400ng/ml (HR 4, CI 1.8-9, P =0.001) were predictors of recurrence. Patients outside Milan criteria were grouped into low- and high-risk hepatocellular carcinoma based on tumor size and AFP. For low-risk hepatocellular carcinoma (tumor size < 6cm, any tumor number, AFP < 400ng/ml), the 5-year recurrence risk was comparable to Milan criteria and increased the transplant pool by 35.7% (P > 0.5). The median number of tumors in the high-risk group, low-risk group, and Milan criteria were 2 (1-3.2), 4(2-5), and 1(1-2) (P <0.001), and the rate of microvascular invasion was 13/18 (72.2%), 22/50 (44%), and 32/140 (22.8%), respectively (P <0.001). ConclusionsThe expanded criteria met the benchmark for 5-year survival. Living donor liver transplantation for the expanded low-risk hepatocellular carcinoma group was associated with an acceptable recurrence risk.