Abstract Background There are no studies evaluating the survival benefit of liver transplantation over alternative therapies for patients with hepatocellular carcinoma. Methods The short- to mid-term survival benefit (study group = 135 aggressively treated patients with hepatocellular carcinoma, 52% beyond Milan criteria at pathology) was calculated by comparing the mortality rates of liver transplantation vs alternative therapies patients. A Markov prediction model was then created to estimate the long-term survival benefit of liver transplantation (gain in life expectancy) over alternative therapies. The long-term survival rates in the liver transplantation group were calculated using the Metroticket website calculator (http://89.96.76.14/metroticket/calculator/). Results The short- to mid-term analysis indicated that liver transplantation afforded no significant survival benefit in the group of patients with hepatoma as a whole (hazard ratio = 1.229, 95% confidence interval 0.544–2.773, p = .6200). The benefit was concentrated in patients with a poor initial response to alternative therapies (hazard ratio = 3.137, 95% confidence interval 1.428–6.891, p = .0044). In the long-term analysis, the gain in life expectancy of liver transplantation vs alternative therapies was 6.115 years (base-case analysis) and the main determinants of gain in life expectancy were the 5-year survival prospects after alternative therapies and the patient's age. Conclusions The survival benefit of liver transplantation for patients with hepatocellular carcinoma is strongly related to the patient's age and the effectiveness of available alternative therapies.