Predictors of non‐transplantable recurrence in hepatocellular carcinoma patients treated with frontline liver resection

Background and Aims: Hepatocellular carcinoma (HCC) recurrence is common in patients treated with liver resection (LR). In this study, we aimed to evaluate the incidence and preoperative predictors of non-transplantable recurrence in patients with single HCC <= 5 cm treated with frontline LR.Methods: From the Italian Liver Cancer (ITA. LI.CA) database, 512 patients receiving frontline LR for single HCC <= 5 cm were retrieved. Incidence and predictors of recurrence beyond Milan criteria (MC) and up-to- seven criteria were compared between patients with HCC <4 and >= 4 cm.Results: During a median follow-up of 4.2 years, the overall recurrence rate was 55.9%. In the >= 4 cm group, a significantly higher proportion of patients recurred beyond MC at first recurrence (28.9% vs. 14.1%; p < 0.001) and overall (44.4% vs. 25.2%; p < 0.001). Similar results were found considering recurrence beyond up-to-seven criteria. Compared to those with larger tumours, patients with HCC <4 cm had a longer recurrence-free survival and overall survival. HCC size >= 4 cm and high alpha-fetoprotein (AFP) level at the time of LR were independent predictors of recurrence beyond MC (and up-to-seven criteria). In the subgroup of patients with available histologic information (n = 354), microvascular invasion and microsatellite lesions were identified as additional independent risk factors for non-transplantable recurrence.Conclusions: Despite the high recurrence rate, LR for single HCC <= 5 cm offers excellent long-term survival. Non-transplantable recurrence is predicted by HCC size and AFP levels, among pre- operatively available variables. High-risk patients could be considered for frontline LT or listed for transplantation even before recurrence.