Beyond Morphology: Pretransplant Tumor-to-Liver FDG Uptake Ratio Predicts Hepatocellular Carcinoma Recurrence After Liver Transplantation
- 1Department of Surgery, Bahçelievler Medipol University Hospital, Istanbul Medipol University, Istanbul 34197, Türkiye
- 2Department of Surgery, Faculty of Medicine, Hacettepe University, Ankara 06100, Türkiye
- 3Department of Liver Transplantation, Istanbul Florence Nightingale Hospital, Istanbul 34381, Türkiye
Abstract
Background/Objectives: Tumor size and number do not fully capture the risk of hepatocellular carcinoma (HCC) recurrence after liver transplantation. We examined whether the pretransplant tumor-to-liver maximum standardized uptake value (SUV) ratio on 18F-FDG PET/CT is associated with recurrence, and assessed the previously reported cutoff of 1.43 in an independent cohort. Methods: We retrospectively analyzed 227 adults who underwent liver transplantation for HCC between July 2004 and November 2024 and had pretransplant FDG PET/CT. The primary endpoint was time to recurrence (TTR). The SUV ratio was analyzed as a continuous, log2-transformed variable in Cox models adjusted for age, MELD-Na, alpha-fetoprotein (AFP), and Milan status; the 1.43 cutoff was a secondary analysis. Death without recurrence was treated as a competing event. Results: Over a median follow-up of 80 months, 43 patients developed recurrence and 86 died. Each doubling of the SUV ratio was associated with a higher recurrence rate (adjusted HR 6.68; 95% CI 3.58–12.47) and higher mortality (HR 2.79; 95% CI 1.72–4.53). The 5-year cumulative incidence of recurrence was 44.7% with a ratio >1.43 and 7.5% with a ratio ≤1.43. Only 2 of 51 non-FDG-avid tumors recurred. The ratio added prognostic information to Milan criteria and AFP (likelihood ratio χ2 28.5; p < 0.001) and stratified risk within the Milan criteria (5-year cumulative incidence of recurrence, 26.4% vs. 5.2%). Conclusions: A high pretransplant tumor-to-liver SUV ratio was strongly associated with recurrence independently of Milan status and AFP. External validation with standardized PET protocols is needed before clinical use.
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BibTeX
@article{atasever2026beyond,
title = {{Beyond Morphology: Pretransplant Tumor-to-Liver FDG Uptake Ratio Predicts Hepatocellular Carcinoma Recurrence After Liver Transplantation}},
author = {Ahmet Atasever and Sinan Efe Yazici and Yildiray Yuzer},
journal = {Journal of Clinical Medicine},
year = {2026},
month = nov,
doi = {10.3390/jcm15218611},
url = {https://www.mdpi.com/2077-0383/15/21/8611},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Beyond Morphology: Pretransplant Tumor-to-Liver FDG Uptake Ratio Predicts Hepatocellular Carcinoma Recurrence After Liver Transplantation
AU - Ahmet Atasever
AU - Sinan Efe Yazici
AU - Yildiray Yuzer
PY - 2026
DA - 2026/11/05
JO - Journal of Clinical Medicine
DO - 10.3390/jcm15218611
UR - https://www.mdpi.com/2077-0383/15/21/8611
AB - Background/Objectives: Tumor size and number do not fully capture the risk of hepatocellular carcinoma (HCC) recurrence after liver transplantation. We examined whether the pretransplant tumor-to-liver maximum standardized uptake value (SUV) ratio on 18F-FDG PET/CT is associated with recurrence, and assessed the previously reported cutoff of 1.43 in an independent cohort. Methods: We retrospectively analyzed 227 adults who underwent liver transplantation for HCC between July 2004 and November 2024 and had pretransplant FDG PET/CT. The primary endpoint was time to recurrence (TTR). The SUV ratio was analyzed as a continuous, log2-transformed variable in Cox models adjusted for age, MELD-Na, alpha-fetoprotein (AFP), and Milan status; the 1.43 cutoff was a secondary analysis. Death without recurrence was treated as a competing event. Results: Over a median follow-up of 80 months, 43 patients developed recurrence and 86 died. Each doubling of the SUV ratio was associated with a higher recurrence rate (adjusted HR 6.68; 95% CI 3.58–12.47) and higher mortality (HR 2.79; 95% CI 1.72–4.53). The 5-year cumulative incidence of recurrence was 44.7% with a ratio >1.43 and 7.5% with a ratio ≤1.43. Only 2 of 51 non-FDG-avid tumors recurred. The ratio added prognostic information to Milan criteria and AFP (likelihood ratio χ2 28.5; p < 0.001) and stratified risk within the Milan criteria (5-year cumulative incidence of recurrence, 26.4% vs. 5.2%). Conclusions: A high pretransplant tumor-to-liver SUV ratio was strongly associated with recurrence independently of Milan status and AFP. External validation with standardized PET protocols is needed before clinical use.
SN - 2077-0383
ER -