Tumour necrosis as a prognostic indicator in hepatocellular carcinoma

Background Tumour necrosis is linked to worse outcomes in hepatocellular carcinoma (HCC). However, the relationship between the extent of necrosis in HCC and survival outcomes remains unclear, partly due to the lack of a standardised assessment method. This study analysed the prognostic significance of tumour necrosis and compared three quantification methods. Methods This retrospective study included 96 HCC patients from two Finnish centres, treated with surgical resection from 1986 to 2022. The extent of necrosis was assessed using three methods: (1) The average percentage method (proportion of necrosis relative to total tumour area), (2) the hotspot method (proportion of necrosis within a 2 mm hotspot), and (3) the linear method (diameter of the largest necrotic focus). Results Tumour necrosis was an independent risk factor for 5-year overall (HR 2.80, 95% CI 1.26–6.22, P = 0.011) and disease-specific mortality (HR 3.89, 95% CI 1.45–10.47, P = 0.007). Tumours with low (but nonzero) necrosis level, as measured by the average percentage, hotspot, and linear methods, were linked to poorer 5-year overall and disease-specific survival compared to tumours without necrosis. Conclusion Tumour necrosis is an independent risk factor for overall and disease-specific mortality in resected HCC. Lower (but nonzero) levels of necrosis were more strongly associated with a worse prognosis when compared with extensive necrosis, suggesting a complex relationship between tumour necrosis and disease progression.