Early Recurrence of Hepatocellular Carcinoma After Hepatectomy: Predictive Role of Whole-Tumor Iodine Density Histogram Features and Resection Margin Distance

Purpose To evaluate the predictive value of whole-tumor iodine density (ID) histogram parameters and resection margin distance for early recurrence (ER) after curative resection of hepatocellular carcinoma (HCC). Methods This retrospective study included patients with HCC who underwent R0 resection and received preoperative spectral CT scans. Patients were categorized into ER+ (n = 42) and ER− (n = 43) groups. Independent predictors of recurrence-free survival (RFS) were identified using multivariate Cox regression analysis. The performance of the prediction model was assessed using time-dependent receiver operating characteristic (td-ROC) curves, calibration and decision curves analysis. Kaplan-Meier analysis was used to evaluate differences in RFS between groups. Results Multivariate Cox regression identified Max, Skewness, microvascular invasion (MVI), and resection margin distance as independent risk factors for ER. Kaplan-Meier analysis revealed significantly shorter mean RFS in patients with MVI+ (12.34 months vs. 29.02 months), extremely narrow margin (9.54 months) and narrow margin (15.42 months) compared to wide margin (28.41 months), high Max (≥ 2041.00 vs. <2041.00; 15.15 vs. 26.13 months), and high Skewness (≥ 0.22 vs. <0.22; 16.83 vs. 23.62 months) (all P  < 0.05). Conclusion Whole-tumor ID histogram parameters (Max and Skewness) and clinicopathological factors (MVI and resection margin distance) are independent predictors of ER. These factors allow effective stratification of RFS and may guide individualized postoperative management. Critical relevance statement: Whole-tumor iodine density histogram features and resection margin distance provide independent predictors of early recurrence after hepatectomy in HCC, enabling improved risk stratification and guiding individualized postoperative management.