Our results showed a significant association between the elevated NLR and the tumor size, AFP level, and macrovascular invasion. Taken together, these results indicated that preoperative elevated NLR can indirectly reflect tumor burden, malignancy, invasion, and metastasis. We found that more than 3 tumor nodules were an independent predictor of recurrence. The result was concomitant with some studies but not the others. Multiple tumor nodules can be categorized into two types: multifocal occurrence and intrahepatic metastasis. HCC patient with intrahepatic metastasis has a poorer prognosis than those with multifocal occurrence. Although fast developed imaging techniques can detect small intrahepatic metastasis, we can not accurately distinguish intrahepatic metastasis from multifocal occurrence based on preoperative imaging. However, in our current study including 27 Torin 1 patients with tumor size.8 cm, we notified that multiple small satellite nodules seemed to surround a large main tumor. The different background of hepatitis may also partly explain that our results were different from that of other publications from Japan or Europe. HCC patients with HCVassociated cirrhosis have a higher incidence of multifocal occurrence than patients with HBV-related cirrhosis. Based on multivariate analysis, we have therefore established a simple preoperative prognostic score model that is superior to the Milan, UCSF and HangZhou criteria at predicting recurrence, with an AUC of 0.781. All patients with a score of 3 showed tumor recurrence within 6 months after LT. The median DFS for patients with a score of 2 and 3 were 3.8 and 8.5 months, respectively. Clearly, LT for these patients is futile. As for patients without macrovascular invasion on radiological findings, all 3 patients with scores of 2, who got recurrence within 14 months after LT, had hazard ratios of 31.810 with an AUC of 0.705. Whereas patients with a score of 0 or 1 may achieve similar survival outcomes as patients within HangZhou criteria, but including more patients. These results indicated that patients without vascular invasion but with both elevated NLR and more than 3 tumor nodules were also not a good indication for LT. A similar study has demonstrated that a scoring model based on NLR before treatment offers a very informative method for predicting prognosis of gastric cancer. Although we demonstrated the prognostic value of NLR in predicting recurrence, it would not be appropriate to conclude that LT should not be considered only because preoperative NLR is high. There are many other factors affecting NLR, such as an acute undetected infection, which affects the accuracy of prognostic prediction. In addition, all patients enrolled had a history of hepatitis B, which may bias the study since hepatitis C is the most common predisposing factor to HCC development in Western countries and Japan. In addition, our study was limited by the retrospective nature of the analysis and the relatively small number of patients was included in the report. Clearly, further prospective studies are needed to confirm and update our preoperative prognostic score model for the prediction of posttransplant tumor recurrence in patients with HCC.