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Simple Summary Li-RADS classification has recently emerged as an accurate tool for hepatocellular carcinoma diagnosis in the setting of liver cirrhosis, but its prognostic value has never been investigated so far. Single HCC benefits from both surgical resection and percutaneous ablation, although several studies support the superiority of surgery in terms of oncological results. We retrospectively and blindly classified 140 treatment-naïve single HCC according to Li-RADS protocol, comparing the oncological outcomes of surgical resection and percutaneous ablation for each Li-RADS subclass. Our analysis highlighted better overall survival, recurrence free survival and lower incidence of local recurrence after surgical resection in Li-RADS-5 nodules, while Li-RADS-3/4 subclasses showed similar outcomes after the two treatments. These results confirm the superiority of surgical approach for single HCC and suggest a potential prognostic role of Li-RADS classification, supporting liver resection especially for Li-RADS-5 subclass. Abstract Background: Single hepatocellular carcinoma (HCC) benefits from surgical resection (SR) or US-guided percutaneous ablation (PA), although the best approach is still debated. We evaluated the impact of Li-RADS classification on the oncological outcomes of SR vs. PA as single HCC first-line treatment. Methods: We retrospectively and blindly classified treatment-naïve single HCC that underwent SR or PA between 2010 and 2016 according to Li-RADS protocol. Overall survival (OS), recurrence free survival (RFS) and local recurrence after SR and PA were compared for each Li-RADS subclass before and after propensity-score matching (PS-M). Results: Considering the general population, SR showed better 5-year OS (68.3% vs. 52.2%; p = 0.049) and RFS (42.5% vs. 29.8%; p = 0.002), with lower incidence of local recurrence (8.2% vs. 44.4%; p < 0.001), despite a significantly higher frequency of clinically-relevant complications (12.8% vs. 1.9%; p = 0.002) and a higher Comprehensive Complication Index (12.1 vs. 2.2; p < 0.001). Focusing on different Li-RADS subclasses, we highlighted better 5-year OS (67.1% vs. 46.2%; p = 0.035), RFS (45.0% vs. 27.0% RFS; p < 0.001) and lower incidence of local recurrence (9.7% vs. 48.6%; p < 0.001) after SR for Li-RADS-5 HCCs, while these outcomes did not differ for Li-RADS-3/4 subclasses; such results were confirmed after PS-M. Conclusions: Our analysis suggests a potential prognostic role of Li-RADS classification, supporting SR over PA especially for Li-RADS-5 single HCC.

The comprehensive assessment of the transplantable tumor (TT) proposed and included in the last Italian consensus meeting still deserve validation. All consecutive patients with hepatocellular carcinoma (HCC) listed for liver transplant (LT) between January 2005 and December 2015 were post-hoc classified by the tumor/patient stage as assessed at the last re-staging-time (ReS-time) before LT as follow: high-risk-class (HRC) = stages TTDR, TTPR, intermediate-risk-class (IRC) = TT0NT, TTFR, TTUT, low-risk-class (LRC) = TT1, TT0L, TT0C. Of 376 candidates, 330 received LT and 46 dropped-out. Transplanted patients were: HRC for 159 (48.2%), IRC for 63 (19.0%), LRC for 108 (32.7%). Cumulative incidence function (CIF) of tumor recurrence after LT was 21%, 12%, and 8% at 5-years and 27%, 15%, and 12% at 10-years respectively for HRC, IRC, and LRC (P = 0.011). IRC patients had significantly lower CIF of recurrence after LT if transplanted &gt, 2-months from ReS-time (28% vs 3% for &lt, 2 and &gt, 2 months, P = 0.031). HRC patients had significantly lower CIF of recurrence after-LT if transplanted &lt, 2 months from the ReS-time (10% vs 33% for &lt, 2 months, P = 0.006). The proposed TT staging system can adequately describe the post-LT recurrence, especially in the LRC and HRC patients. The intermediate-risk-class needs to be better defined and further studies on its ability in defining intention-to-treat survival (ITT) and drop-out are required.