Abstract
Background and aims: Liver transplantation (LT) is a curative option for hepatocellular carcinoma (HCC). However, HCC recurrence and the limited accuracy of current morphological criteria remain unresolved issues. This study investigated the association between preoperative magnetic resonance imaging (MRI)–derived fat fraction (FF) and survival in patients with HCC undergoing LT. Methods: We retrospectively reviewed 42 patients with HCC who underwent orthotopic LT. Preoperative FF was obtained from dual-echo T1-weighted imaging, and patients were categorized into low- ( n = 24) or high-FF groups ( n = 18) using a 6.074% threshold. Clinical data, perioperative features, and outcomes were analyzed. Disease-free survival (DFS) and disease-specific survival (DSS) were assessed using Cox regression and Kaplan–Meier analyses. Results: Baseline characteristics were comparable between the two groups, except for higher cholesterol level in the low-FF group. Elevated alpha-fetoprotein level (≥40 ng/mL) was independently associated with shorter DFS (hazard ratio [HR] = 3.649; 95% confidence interval [CI]: 1.002–13.289; p < 0.05). For DSS, FF emerged as an independent protective factor (HR = 0.848; 95% CI: 0.746–0.965; p = 0.012). Glucose level (HR = 0.852; 95% CI: 1.118–3.066; p = 0.017) and increased gamma-glutamyl transferase level (HR = 1.005; 95% CI: 1.001–1.008; p = 0.006) were linked to poorer DSS. Kaplan–Meier analysis demonstrated longer DSS in the high-FF group, with no differences in DFS. Conclusion: Preoperative MRI-derived FF is independently associated with DSS after LT in patients with HCC. FF assessment may complement the Milan criteria and improve candidate selection, thereby supporting clinical decision-making.