Multicenter Validation of a RAR-Based Nomogram for Predicting Postoperative Progression in HBV-Related Hepatocellular Carcinoma.

[BACKGROUND] The red cell distribution width-to-albumin ratio (RAR) is a biomarker reflecting systemic inflammation and oxidative stress, and has been associated with outcomes in multiple diseases. However, its value for predicting postoperative recurrence or progression in hepatitis B virus-related hepatocellular carcinoma (HBV-HCC) remains undetermined.

[METHODS] We retrospectively reviewed 1 011 HBV-HCC patients who underwent surgical treatment at three tertiary centres. Patients were divided into training, internal validation and external validation cohorts. The performance of RAR for predicting progression-free survival (PFS) was assessed using receiver operating characteristic (ROC) analysis, and restricted cubic spline (RCS) modelling was used to explore its nonlinear association with progression risk. Independent prognostic factors were identified by multivariate Cox regression and incorporated into a nomogram and an interactive web-based calculator, which were validated in all cohorts.

[RESULTS] RAR achieved an area under the ROC curve (AUC) of 0.662 for predicting PFS. RCS analysis revealed a nonlinear increase in progression risk with rising RAR values, with the curve plateauing at higher levels. Multivariate Cox analysis confirmed RAR as an independent predictor of postoperative PFS (hazard ratio [HR] = 4.40; 95% CI, 1.74-11.12). The nomogram-integrating RAR, tumour size, alpha-fetoprotein, TNM stage and portal vein tumour thrombus (PVTT)-demonstrated Satisfactory discrimination, excellent calibration and consistent net clinical benefit across data sets.

[CONCLUSION] RAR independently predicts postoperative recurrence or progression in HBV-HCC. The RAR-based nomogram offers a practical tool for individualised estimation of PFS, facilitating more precise postoperative risk stratification and management.