For smaller HCC, many studies have shown that direct radical surgery, such as liver transplantation and hepatectomy, is beneficial to the prognosis of patients [12, 13]. However, some studies have suggested that treatment to reduce the size of the tumor before radical surgery may benefit the prognosis of patients with relatively large HCC [9, 10]. However, there is still a lack of studies to investigate the independent prognostic risk factors after hepatectomy in patients with HCC larger than 2 cm.

This study identified independent prognostic risk factors in 438 patients with HCC larger than 2 cm who underwent hepatectomy. The independent risk factors included preoperative TACE, age, BCLC stage, PNI, tumor longest diameter, and AFP. Preoperative TACE can reduce the tumor, reduce the tumor burden of HCC patients, and control the tumor progression before radical surgery, so it is beneficial to the prognosis of patients. For patients with large tumors, TACE can be used before hepatectomy to improve the prognosis of patients [14, 15]. The age and PNI of HCC patients represented the basic condition of the patients. PNI is calculated from albumin and lymphocyte levels and therefore represents the nutritional status and immune capacity of the patient. Many studies have shown that PNI is an independent risk factor for patients with many tumors, including HCC. Therefore, older age and lower PNI may be associated with poor nutritional status and weak immune function, which is not conducive to improving the prognosis of cancer patients after treatment [8, 16,17,18,19]. BCLC stage, tumor longest diameter, and AFP are the characteristics of HCC. The higher the BCLC stage, the larger the maximum tumor diameter, and the higher the AFP level, represents the larger tumor burden of HCC patients and even represents the bad biological characteristics of HCC, which predicts the poor prognosis of HCC patients [20,21,22,23,24].

Based on these independent prognostic risk factors, a nomogram was constructed to predict OS after hepatectomy in patients with HCC larger than 2 cm. The nomogram was evaluated by calculating the C-index, drawing calibration curves and decision analysis curves, and had effective predictive ability. Moreover, these independent risk factors are easy to obtain in clinical practice, indicating that the construction of the nomogram is simple and feasible. Compared with expensive genetic testing, it can reduce the economic burden of HCC patients [25]. This practical nomogram can be generalized to lower care Settings to predict OS in patients with larger than 2 cm HCC after hepatectomy. In some previous studies, there were also some studies based on PNI or TACE to predict the prognosis of HCC patients after surgery. Some studies have constructed a nomogram based on PNI to predict the prognosis of elderly HCC patients [8]. There are also studies that have developed prognostic models to predict the prognosis of HCC patients who received TACE downstaging treatment and then underwent surgery. Several studies have also investigated the risk factors for poor prognosis in HCC patients treated with adjuvant TACE after radical surgery [26, 27]. However, no study has constructed a nomogram based on both PNI and preoperative TACE to predict the prognosis of patients with a diameter of > 2 cm HCC after surgery. The larger the tumor, the larger the tumor burden, which may be an important reason for the poor prognosis of HCC patients. Therefore, there may be a trend for patients with HCC larger than 2 cm to receive preoperative TACE downstaging treatment. The construction of an effective nomogram based on this may show the importance of preoperative TACE for HCC patients with large tumors.

Based on this study, it should be recognized that the nutritional status and tumor burden of HCC patients before treatment are very important in clinical practice. For patients with poor nutritional status and large tumor burden, it is necessary to improve their nutritional status and reduce their tumor burden before undergoing hepatectomy. These measures are helpful in improving the prognosis of patients and prolonging the overall survival of patients after surgery. Based on the nomogram constructed in this study, it can predict the OS of patients with HCC larger than 2 cm when radical resection is required in clinical practice. If the predicted prognosis is not good, the basic condition of the patient should be improved in advance, such as improving the nutritional status and performing TACE to downstage the tumor. In addition, these patients may receive adjuvant therapy with targeted drugs and immune drugs after surgery, to prolong the OS of HCC patients. This is the meaning of this clinical study.

However, this study has the following limitations. Firstly, this study is retrospective, and there is a lack of prospective studies to further verify its conclusions. Secondly, this study is a single-center study with weak power, and multi-center studies are still needed to enhance the power. In addition, the nomogram constructed in this study has only been internally validated, and external data from other centers are needed for further validation. Finally, the nomogram constructed in this study was only applicable to predict OS in patients with HCC larger than 2 cm after hepatectomy, and whether it is applicable to other HCC patients has not been demonstrated.