Development of a Nomogram Model to Predict Post-Transplant Tumor Recurrence in Patients with Hepatocellular Carcinoma Beyond the Milan Criteria Undergoing TACE Bridging Therapy

Objective: To develop a nomogram based on clinical characteristics for predicting post-transplant tumor recurrence in hepatocellular carcinoma (HCC) patients beyond the Milan criteria who received transarterial chemoembolization (TACE) bridging therapy. Methods: A retrospective analysis included 73 such patients (29 conventional TACE [cTACE], 44 drug-eluting bead TACE [DEB-TACE]) who underwent liver transplantation at our institution between January 2013 and January 2020, with follow-up until January 2024 (mean: 33.2 ± 6.5 months). Clinical/pathological features were analyzed via univariate and multivariate Cox regression to identify recurrence-related factors, and a nomogram was constructed. Bootstrap validation (B=20) and receiver operating characteristic (ROC) curves (AUC) evaluated its performance. Results: The 1-, 2-, 3-year cumulative recurrence rates were 17.8%, 23.3%, 24.7% (median recurrence time: 6 months). cTACE group rates (20.7%, 27.6%, 31.0%) were higher than DEB-TACE (15.9%, 20.5%, 20.5%; P=0.034). Independent risk factors: bridging therapy type (HR=2.402, P=0.034), microvascular invasion (HR=3.445, P=0.001), tumor necrosis rate (HR=26.664, P=0.002), pre-TACE AFP (HR=2.750, P=0.004). The nomogram's AUC for 1-, 2-, 3-year recurrence was 0.740, 0.764, 0.886, with good calibration via bootstrap. Conclusion: A nomogram based on clinical characteristics accurately predicts post-transplant recurrence in HCC patients beyond the Milan criteria with TACE bridging therapy, providing guidance for optimizing donor allocation.