Hepatocellular carcinoma (HCC) remains associated with a high risk of recurrence, with 5-year recurrence rates approaching 70% after curative hepatectomy. The Chinese Liver Cancer Staging guideline strongly recommend transarterial chemoembolization (TACE) as an adjuvant therapy to reduce postoperative recurrence and improve overall survival. However, its clinical benefit remains controversial, as guidelines from other regions do not support routine use of adjuvant TACE. This discrepancy may reflect the possibility that adjuvant TACE primarily facilitates detection of intrahepatic residual lesions through digital subtraction angiography (DSA), rather than conferring direct therapeutic benefit from embolic or chemotherapeutic agents.

This multicenter, phase Ⅲ randomized controlled trial will enroll 442 eligible participants, who will be randomly assigned in a 1:1 ratio to either an adjuvant TACE group or an intensive follow-up group. The primary endpoint of this study is to investigate whether adjuvant TACE could improve recurrence-free survival (RFS) in high-risk HCC patients following curative hepatectomy. The key secondary endpoints include the safety and tolerability of adjuvant TACE, as well as the effects of adjuvant TACE versus intensive follow-up on overall survival, median RFS, and time to tumor recurrence. This trial may addresses the critical clinical controversy regarding adjuvant TACE by excluding patients with residual tumor staining on DSA, to ensure genuine curative resection. The results will deliver high-quality evidence to clarify the efficacy and safety of adjuvant TACE, and standardize postoperative adjuvant strategies.

Hyper-progression recurrence (HPR) after hepatectomy is a specific recurrence pattern associated with extremely poor prognosis in patients with hepatocellular carcinoma (HCC). This study was aimed at investigating the probable risk factors and establishing comprehensive models for formulating clinical strategies.

Overall, 16,158 patients with HCC from 8 hospitals were screened, among whom 3,125 patients who underwent R0 resection were included, and divided into development (n = 2,113) and validation (n = 1,012) cohorts. A comprehensive study of HPR predictive models and biological features was conducted.

Among the 3,125 enrolled patients, 506 (16.19%) developed HPR. The influence of HPR on extremely poor prognosis was reflected by recurrence features, adverse effects on systemic and liver function, and limited therapeutic options. Nine variables closely associated with HPR were identified, and incorporated into nomogram and conditional inference tree models, which successfully achieved pre- and post-operative HPR risk stratification and facilitated clinical decision-making. Multi-dimensional verification also confirmed the predictive accuracy of model combinations and their reliability in clinical applications. Furthermore, biological analyses revealed that HCCs with HPR exhibited hyperactive biological processes, inactive metabolism, and immune exhaustion features, together with high MYCN/HMGA2 co-expression, thereby enhancing understanding of the molecular events leading to HPR and providing valuable knowledge for HPR management.

HPR after hepatectomy is associated with extremely poor prognosis and requires substantial attention. We constructed comprehensive predictive models and propose a clinical strategy for guiding HPR prevention and management.