Prognostic Significance of PET-SUVmax in Patients Undergoing Resection of Hepatocellular Carcinoma >3 cm: A Retrospective Analysis

Background and Aims Hepatocellular carcinoma (HCC) > 3 cm often recurs after resection, indicating a need for better risk stratification. The 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) maximum standardized uptake value (SUVmax) reflects tumor aggressiveness. In this study, we aimed to evaluate the prognostic significance of preoperative FDG-PET SUVmax in patients with resectable initial HCC > 3 cm. Methods This retrospective analysis included data of 136 patients who had undergone curative resection for HCC > 3 cm between 2012 and 2021, all of whom had undergone preoperative FDG-PET imaging. Patients were classified into low and high uptake groups based on tumor SUVmax. We investigated the association between PET findings and clinicopathological factors. Results Patients with high SUVmax had significantly worse overall survival than did those with low SUVmax (49.2% vs. 90.0%, p < 0.0001). According to multivariate analysis, high SUVmax was an independent predictor of both poor overall survival (HR 3.09, 95% CI 1.35–7.06, p = 0.0077) and poor recurrence-free survival (33.4% vs. 60.4%, p = 0.0006). High SUVmax was strongly associated with microscopic vascular invasion (mvi). Notably, the combination of high SUVmax and high alpha-fetoprotein significantly improved the preoperative prediction of mvi. Conclusions Preoperative FDG-PET SUVmax is an independent prognostic biomarker in patients with HCC > 3 cm and, when combined with serum alpha-fetoprotein, may enhance prediction of mvi noninvasively. These findings support incorporating metabolic imaging into preoperative risk models to guide surgical and perioperative management strategies.