Construction of a nomogram integrating magnetic resonance imaging features and Ephrin-A3 expression to predict postoperative overall survival in hepatocellular carcinoma

Construction of a nomogram integrating magnetic resonance imaging features and Ephrin-A3 expression to predict postoperative overall survival in hepatocellular carcinoma | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Construction of a nomogram integrating magnetic resonance imaging features and Ephrin-A3 expression to predict postoperative overall survival in hepatocellular carcinoma Yanyan Zhang, Lijuan Feng, Qianjuan Chen, Siyuan Tan, Wanyun Huang, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7628199/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract This study aimed to explore the relationship between Ephrin-A3 expression and postoperative overall survival (OS) in hepatocellular carcinoma (HCC) patients and to develop a prognostic nomogram integrating clinical, pathological, MRI features, and Ephrin-A3 expression. We conducted a retrospective analysis of 111 HCC patients, from whom clinical, pathological, and MRI data were collected, and Ephrin-A3 immunohistochemistry was performed. Using an optimal cut-off value of averaged optical density (AOD) derived from Ephrin-A3 staining to predict OS, patients were categorized into high and low expression groups. The cohort was randomly split into training (70%) and validation (30%) sets. Univariate and multivariate Cox regression analyses identified Ephrin-A3 expression, tumor margin, nonrim arterial phase hyperenhancement, and extrahepatic metastasis as independent predictors of OS. A nomogram was subsequently developed to predict postoperative OS. The model demonstrated concordance indexes of 0.76 and 0.72 in the training and validation sets, respectively. The area under the curve (AUC) values for predicting 12-, 36-, and 60-month OS were 0.790, 0.790, and 0.776 in the training set, and 0.970, 0.737, and 0.770 in the validation set. Kaplan–Meier survival analysis confirmed significantly longer OS in the low-risk group in both datasets. Calibration curves indicated strong agreement between predicted and observed survival probabilities, and decision curve analysis (DCA) confirmed the clinical utility of the model. In conclusion, Ephrin-A3 serves as an independent prognostic factor for OS in HCC patients after surgery, and the constructed nomogram exhibits favorable predictive performance for postoperative survival. Health sciences/Biomarkers Biological sciences/Cancer Health sciences/Oncology Hepatocellular carcinoma Hypoxia MRI Overall survival EFNA3 Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Hepatocellular carcinoma (HCC) ranks among the most common and deadly cancers globally, exhibiting rising incidence and mortality rates 1 . China alone reported roughly 410,000 new HCC cases in 2020, accounting for 45.3% of global new cases 2 . Although various HCC treatments exist, the 5-year survival rate remains low (15–38%) because most cases are detected at advanced stages, exhibit chemotherapy resistance, and show high rates of recurrence and metastasis 3 . EFNA3 is a hypoxia-related gene, and its expression is directly or indirectly regulated by hypoxia-inducible factor-1α (HIF-1α) 4–7 . Its protein product, ephrin-A3, functions as a cell-surface ligand that binds Eph receptor tyrosine kinases, mediating neuronal, vascular, and epithelial cell migration, repulsion, and adhesion 5 . The Eph-ephrin signaling axis contributes to axon guidance and influences critical oncogenic processes, including cancer cell proliferation, invasion, metastasis, and angiogenesis 8 . In gastric cancer, elevated EFNA3 mRNA expression correlates with poor prognosis and predicts immunotherapy response 9 . Wang, Y. et al. 10 identified elevated EFNA3 expression in bladder urothelial carcinoma tissues through bioinformatic analysis and immunohistochemical (IHC) validation. Patients exhibiting high EFNA3 levels demonstrated markedly reduced overall survival (OS). Lung adenocarcinoma tissues show substantial EFNA3 upregulation, where it drives malignancy through enhanced proliferation and glycolysis, correlating inversely with both OS and progression-free survival 11 . However, EFNA3 displays tumor-suppressive roles in some contexts. The miR-210-3p-Ephrin-A3 -PI3K/AKT axis suppresses Ephrin-A3 expression to promote oral squamous cell carcinoma progression 12 . EFNA3 similarly acts as a tumor suppressor in malignant peripheral nerve sheath tumors 13 . Although elevated EFNA3 mRNA levels correlate with OS in HCC patients 14 , 15 , the IHC expression of Ephrin-A3 has not been reported to predict postoperative OS in HCC patients. Magnetic Resonance Imaging (MRI) has become an increasingly vital diagnostic tool, offering detailed insights into organ anatomy, physiological function, and metabolic activity. MRI outperforms other imaging modalities in detecting and monitoring liver lesions, owing to its superior soft tissue contrast, diverse scanning sequences, and advanced techniques. These include enhanced data acquisition, refined image reconstruction, improved denoising algorithms, reduced artifacts, and the application of hepatocyte-specific contrast agents 16 . Gadolinium ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA) is a liver-specific contrast agent with the highest efficiency in its class and has been widely adopted in clinical practice 17 , 18 . In addition to providing dynamic contrast-enhanced imaging comparable to conventional extracellular contrast agents, Gd-EOB-DTPA-enhanced MRI offers an additional hepatobiliary phase (HBP), which aids in the detection and characterization of liver lesions as well as the assessment of liver function and fibrosis 17 . This study aims to investigate the relationship between Ephrin-A3 expression and postoperative OS in HCC patients and develop a nomogram incorporating clinical, pathological, Gd-EOB-DTPA MRI features, and Ephrin-A3 expression to predict postoperative OS in HCC patients. Materials and methods Research objects This retrospective study qualified for exemption from obtaining patient informed consent. The Medical Ethics Committee of the First Affiliated Hospital of Guangxi Medical University granted ethical approval for this study on August 13, 2025 (2025-E0662) following the principles outlined in the Declaration of Helsinki and the Declaration of Istanbul. Patients with HCC who underwent surgical treatment at the First Affiliated Hospital of Guangxi Medical University between February 11, 2018, and January 10, 2020, were enrolled based on the following inclusion and exclusion criteria. Inclusion criteria: 1) Age 18–80 years; 2) The abdominal Gd-EOB-DTPA MRI enhanced scan was received before the operation; 3) Radical resection within two weeks post-MRI at our center; 4) Histopathologically confirmed HCC. Exclusion criteria: 1) Previous antitumor interventions (embolization, radiotherapy, chemotherapy, ablation, or systemic therapy); 2) Concurrent or prior malignancies; 3) Perioperative death due to severe complications (e.g., cardiac, pulmonary, cerebral, or renal dysfunction) or infection/hemorrhage; 4) Inadequate follow-up documentation; 5) Suboptimal MRI quality. Data collection and follow-up Patient demographic and clinical data, including sex, age, and Barcelona Clinic Liver Cancer (BCLC) stage, were retrieved from the medical record system. Preoperative laboratory parameters included alpha-fetoprotein (AFP), protein induced by vitamin K absence or antagonist-II (PIVKA-II), hepatitis B virus (HBV)-related markers, albumin (ALB), aspartate aminotransferase (AST), alanine transaminase (ALT), total bilirubin (TBIL), and direct bilirubin (DBIL). Pathological data comprised tumor number, Edmondson-Steiner (ES) grade, Ishak fibrosis score, Ishak inflammation score, microvascular invasion (MVI) grade, and IHC vascular endothelial growth factor (VEGF) expression. Follow-up commenced on the surgical date, and guided by the AFP levels and imaging results, augmented by telephone interviews. Patients were followed for at least five years postoperatively or until death. The endpoint of this study was OS, defined as the duration from the date of surgery to the date of death or the last follow-up. Patients who could not be contacted during the follow-up period were recorded as lost to follow-up. MRI acquisition and analysis MRI examinations were performed with 3.0-T system (Siemens MAGNETOM Prisma, 18-channel body array coil). The MRI sequences included T2-weighted two-dimensional fast spin echo imaging, diffusion-weighted imaging (DWI)(b values: 50,400, and 1000 s/mm2) with apparent diffusion coefficient (ADC) maps, T1-weighted dual gradient-echo in- and opposed-phase imaging, and dynamic T1- weighted three-dimensional gradient-echo imaging before and after injection of gadoxetic acid disodium (Primovist®, Bayer Pharma AG) in the late arterial phase, portal venous phase (60 s), transitional phase (3 minutes), and hepatobiliary phase (20 minutes). The arterial phase images were determined either by the acquisition triggered 7 s after the arrival of the contrast bolus in the celiac trunk or by a multiple arterial phase (MAP) imaging technique. Specifically, the MAP images were acquired with an 18 s breath hold 20 s following the contrast agent injection and further reconstructed with a temporal resolution of 3 s. For dynamic imaging, the contrast agent was injected at a rate of 1–2 ml/s for a total dose of 0.025 mmol/kg body weight, followed by 20–30 ml of 0.9% saline flush. Details of the MRI sequences and parameters are shown in Table S1 . Two abdominal radiologists (with 5 and 10 years of experience, respectively) independently evaluated all MR images without access to clinical or pathological data. For discordant cases, qualitative imaging features were determined by consensus, whereas quantitative measurements were averaged. Cohen’s kappa coefficient evaluated interobserver agreement for categorical variables, and the intraclass correlation coefficient (ICC) assessed consistency for continuous measurements. Drawing on prior studies 19 – 23 , we assessed 23 qualitative and quantitative features, with detailed descriptions provided in Sup. Table S2. The following features are included: tumor size, apparent diffusion coefficient (ADC) value, tumor margin, marked diffusion restriction, marked T2 hyperintensity, intralesional fat, targetoid restriction, targetoid transitional phase (TP) or HBP appearance, nonrim arterial phase hyperenhancement (APHE), internal artery, nonperipheral "washout", portal venous phase (PVP) peritumoral hypo-enhancement, tumor capsule, intratumoral hemorrhage, nodule-in-nodule architecture, mosaic architecture, intralesional necrosis, tumor in vein, Peritumoral enhancement on arterial phase (AP), Peritumoral hypointensity on HBP, tumor hypointensity on HBP, extrahepatic metastasis, hemorrhage and necrosis. When multiple lesions were present, the analysis focused on the largest one. Immunohistochemistry The primary antibody is the EFNA3 Rabbit pAb (120597, diluted 1:100; Zheng Neng Biotechnology, Chengdu). Representative images (3–5 per sample) were captured under a UC90 microscope (Olympus, Japan). The integrated optical density (IOD) and area were quantified using Image-Pro Plus v6.0 software (Media Cybernetics Inc., Bethesda, MD, USA). The averaged optical density (AOD) was calculated by dividing IOD by the area and was used for subsequent analyses 24 . The optimal cut-off value of AOD for predicting OS was determined using the surv_cutpoint() function from the survminer package. Based on this cut-off, patients were stratified into high- and low-expression groups. Statistical analysis All statistical analyses were conducted in R (version 4.4.2). For continuous variables, normality was assessed using the Shapiro-Wilk test. Normally distributed data were expressed as mean ± standard deviation (SD) and compared between groups with an independent t-test. Non-normally distributed data were summarized as median [P25, P75] and analyzed using the Mann-Whitney U test for intergroup comparisons. Categorical variables appeared as frequencies (percentages), compared between groups with chi-square tests or Fisher’s exact tests when chi-square assumptions were violated. Minor missing values were handled through multiple imputation via the missRange package. Two-tailed tests were applied throughout, with statistical significance set at P < 0.05. The construction and verification process of the nomogram was shown in Fig. 1 . Results Baseline characteristics Between February 2018 and January 2020, we retrospectively evaluated 200 patients, of whom 152 cases with HCC met the inclusion and exclusion criteria. After excluding 41 cases with incomplete follow-up data, 111 patients (99 male, 12 female) with complete survival records were analyzed. Their mean age was 50.09 ± 11.28 years, with a median follow-up of 61 months (range: 3–69). At the final follow-up, 90 patients (81.1%) remained alive, while 21 (18.9%) had died. The study cohort comprised 100 cases (90.1%) with high EFNA3 expression and 11 cases (9.9%) exhibiting low expression. Interobserver agreement for categorical imaging features, measured by kappa statistics, showed good consistency (κ = 0.712–0.920). For ADC values, the ICC reached 0.705. Sup. Table S3 summarizes the baseline patient characteristics. Univariate and multivariate Cox regression analysis The univariate Cox regression analysis conducted on the training set identified EFNA3 expression, PVP peritumoral hypointensity, extrahepatic metastasis, and hemorrhage/necrosis as significant predictors of OS (P 0.05) (Sup. Table S4). Multivariate Cox regression analysis identified EFNA3 expression, nonrim APHE, margin, and extrahepatic metastasis as independent predictors of OS in HCC patients following curative resection (P < 0.05). The forest plot presents the odds ratios (OR) and 95% confidence intervals (CI) for key variables identified by univariate and multivariate Cox regression analysis (Fig. 2 ). Construction and evaluation of the nomogram Figure 3 A presents the constructed nomogram for predicting OS in HCC patients. The calibration curves for both training (Fig. 3 B) and validation (Fig. 3 C) sets showed close agreement between predicted and observed OS probabilities at 12, 36, and 60 months. Time-dependent receiver operating characteristic (ROC) curves yielded AUC values of 0.790, 0.790, and 0.776 at 12, 36, and 60 months in the training set (Fig. 4 A), while the validation set (Fig. 4 B) exhibited values of 0.970, 0.737, and 0.770, respectively. The model achieved a concordance index (C-index) of 0.76 in the training set and 0.72 in the validation set. Figure 4 C illustrates that the C-indexes remained elevated during early follow-up for both cohorts, reflecting stronger discriminative capacity for short-term survival predictions. While the C-index gradually decreased over time, it consistently exceeded 0.7, maintaining clinically meaningful predictive accuracy throughout extended follow-up. Using an optimal nomogram score cut-off of 67.020, patients were stratified into low- and high-risk groups. Kaplan-Meier survival curves revealed significantly prolonged OS in the low-risk group across the training set (Fig. 5 A), validation set (Fig. 5 B), and total patients (Fig. 5 C) (P < 0.05). Decision curve analysis (DCA) demonstrated clinical utility for the model in the training set, with net benefit across threshold probabilities of 0.1–0.5 (12-month), 0.1–0.9 (36-month), and 0.1–0.9 (60-month). In the validation set, the model provided net benefit only for 36- and 60-month predictions (thresholds 0.1–0.9), with no significant benefit at 12 months (Fig. 6 ). Discussion Ephrin-A3, margin, nonrim APHE, and extrahepatic metastasis independently predicted postoperative OS in HCC patients. High Ephrin-A3 expression, smooth tumor margins, nonrim APHE, and the absence of extrahepatic metastasis correlated with prolonged OS. The nomogram incorporating these factors achieved strong predictive accuracy. The validation set yielded an AUC of 0.970 for 12-month predictions, yet DCA revealed no clinical benefit during this period, likely due to the limited number of patients with 12-month OS in the validation cohort. Husain et al. found that HIF-1α directly upregulates EFNA3 expression under hypoxic conditions, with both EFNA3 and Ephrin-A3 protein driving HCC initiation, growth, stemness, and migration 5 . Gómez-Maldonado et al. 6 reported stable EFNA3 mRNA levels during hypoxia but identified HIF-mediated expression of a novel long non-coding RNA from the EFNA3 locus that increased Ephrin-A3 protein accumulation. Fasanaro et al. 7 observed decreased Ephrin-A3 protein expression under hypoxia despite elevated mRNA levels, implicating miR-210-mediated post-transcriptional regulation. While public mRNA databases associate high EFNA3 expression with reduced OS 14,15 , our data align with Fasanaro et al.’s results, showing prolonged OS in high-Ephrin-A3 protein expression cases. The hypoxia-responsive miR-210 enhances angiogenesis, metastasis, and tumor progression across malignancies 25 . HIF-1α-induced miR-210 overexpression suppresses Ephrin-A3 while activating the PI3K/AKT pathway 26 , stimulating endothelial cell proliferation, migration, and angiogenesis. In oral cancer, Ephrin-A3 drives epithelial-mesenchymal transition through PI3K/AKT signaling, accelerating tumor growth, invasion, metastasis, and drug resistance 12 . HCC cells exhibit miR-210-mediated Ephrin-A3 downregulation, whereas cisplatin treatment upregulates Ephrin-A3 and improves chemosensitivity 27 . Ephrin-A3 overexpression increases phosphorylated focal adhesion kinase and tumor necrosis factor-alpha, while reducing PI3K, GTPase, integrins, VEGF, and HIF-1α, suggesting tumor suppression through focal adhesion kinase signaling modulation and VEGF-dependent angiogenesis 13 . Typical HCC exhibits nonrimAPHE. Approximately 40% of HCC cases may lack this feature, particularly in very early-stage or poorly differentiated tumors 28 . Rim APHE, marked by peripheral enhancement, correlates with aggressive histopathological characteristics such as hypoxic and fibrotic microenvironments and elevated stemness 29 . Tumors with smooth margins are often histologically encapsulated and exhibit a lower frequency of invasion into the surrounding liver parenchyma 30 . In contrast, tumors with irregular margins demonstrate a higher incidence of MVI and are associated with poorer 5-year OS and recurrence-free survival 31 . Radiologically, irregular margins often reflect invasive growth, tumor in vein, and extrahepatic metastases 32 . The most frequent extrahepatic metastatic sites are the lungs, intra-abdominal lymph nodes, bones, and adrenal glands, with possible spread to the pleura, peritoneum, and brain. These patients face a dismal prognosis, with a 5-year survival rate of just 3% 33 . In this study, smooth tumor margins, nonrim APHE, and the absence of extrahepatic metastasis correlated with prolonged OS, aligning with previous findings. This study has several limitations. First, due to its retrospective nature, unavoidable selection bias exists, necessitating prospective randomized controlled trials with multiple-group comparisons to mitigate this bias. Second, the insufficient sample size and lack of external validation may affect the model's generalizability, future studies will expand the sample size and conduct external validation to verify the results. Potentially due to the small sample size and selection bias, pathological ES grading, staging, MVI, and other factors that may correlate with OS showed no significant association with OS in this study. Finally, the potential influence of other postoperative treatment modalities in HCC patients cannot be excluded. Conclusions Ephrin-A3, margin, nonrim APHE, and extrahepatic metastasis independently predicted postoperative OS in HCC patients. High Ephrin-A3 IHC expression, smooth tumor margins, nonrim APHE, and the absence of extrahepatic metastasis correlated with prolonged OS. The nomogram incorporating these factors showed good predictive accuracy for postoperative OS in HCC. These findings provide valuable insights for prognostic assessment and therapeutic decision-making in HCC patients. Abbreviations ADC, Apparent Diffusion Coefficient; AFP, alpha-fetoprotein; ALB, albumin; ALT, alanine transaminase; AOD, averaged optical density; AP, arterial phase; APHE, arterial phase hyperenhancement; AST, aspartate aminotransferase; AUC, area under the curve; BCLC, Barcelona Clinic Liver Cancer; C-index, concordance index; DBIL, direct bilirubin; DCA, decision curve analysis; DWI, diffusion-weighted imaging; ES, Edmondson-Steiner; Gd-EOB-DTPA, gadolinium ethoxybenzyl-diethylenetriamine pentaacetic acid; HBP, hepatobiliary phase; HCC, hepatocellular carcinoma; HIF-1α, hypoxia-inducible factor-1α; ICC, intraclass correlation coefficient; IHC, immunohistochemical; IP, in-phase; K-M, Kaplan-Meier; MRI, Magnetic Resonance Imaging; MVI, microvascular invasion; OP, opposed-phase; OS, overall survival; PIVKA-II, protein induced by vitamin K absence or antagonist-II; PVP, portal venous phase; ROC, receiver operating characteristic; TBIL, total bilirubin; TP, transitional phase；VEGF, vascular endothelial growth factor. Declarations Competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Ethical Approval The Medical Ethics Committee of the First Affiliated Hospital of Guangxi Medical University granted ethical approval for this study on August 13, 2025 (2025-E0662) following the principles outlined in the Declaration of Helsinki and the Declaration of Istanbul. Consent to participate Written informed consent was waived by the Institutional Review Board due to the retrospective nature of the study. Funding This study was supported by the Open Project of NHC Key Laboratory of Thalassemia Medicine (NO. GJWJWDP202208) and National Natural Science Foundation of China, Grant/Award Number: 82060310. Author Contribution Y.Z., L.F., Q.C., S.T., and W.H. collected and analyzed the data and prepared the visualizations. Y.Z. wrote the initial draft of the manuscript. L.L. reviewed and edited the manuscript, supervised the study, acquired funding, and developed the conceptual framework. All authors critically evaluated and approved the final version. Acknowledgement We sincerely thank all colleagues and institutions that contributed to this study. Data Availability The data supporting this study's findings are available from the corresponding author upon reasonable request. References Johnson, P., Zhou, Q., Dao, D. Y. & Lo, Y. M. D. Circulating biomarkers in the diagnosis and management of hepatocellular carcinoma. Nature reviews. Gastroenterology & hepatology . 19 , 670-681 (2022). Xie, D., Shi, J., Zhou, J., Fan, J. & Gao, Q. Clinical practice guidelines and real-life practice in hepatocellular carcinoma: A Chinese perspective. Clin. Mol. Hepatol. 29 , 206-216 (2023). Oura, K., Morishita, A., Tani, J. & Masaki, T. Tumor Immune Microenvironment and Immunosuppressive Therapy in Hepatocellular Carcinoma: A Review. International journal of molecular sciences . 22 , 5801 (2021). Mo, Z., Liu, D., Rong, D. & Zhang, S. Hypoxic Characteristic in the Immunosuppressive Microenvironment of Hepatocellular Carcinoma. Front. Immunol. 12 , 611058 (2021). Husain, A. et al. Ephrin-A3/EphA2 axis regulates cellular metabolic plasticity to enhance cancer stemness in hypoxic hepatocellular carcinoma. J. Hepatol. 77 , 383-396 (2022). Gómez-Maldonado, L. et al. EFNA3 long noncoding RNAs induced by hypoxia promote metastatic dissemination. Oncogene . 34 , 2609-2620 (2015). Fasanaro, P. et al. MicroRNA-210 modulates endothelial cell response to hypoxia and inhibits the receptor tyrosine kinase ligand Ephrin-A3. The Journal of biological chemistry . 283 , 15878-15883 (2008). Chen, J. Regulation of tumor initiation and metastatic progression by Eph receptor tyrosine kinases. Adv. Cancer. Res. 114 , 1-20 (2012). Zheng, P. et al. EFNA3 Is a Prognostic Biomarker Correlated With Immune Cell Infiltration and Immune Checkpoints in Gastric Cancer. Front. Genet. 12 , 796592 (2021). Wang, Y. et al. Clinicopathological and prognostic significance of Ephrin A3 in bladder urothelial carcinoma. Oncol. Lett. 26 , 524 (2023). Deng, M. et al. EFNA3 as a predictor of clinical prognosis and immune checkpoint therapy efficacy in patients with lung adenocarcinoma. Cancer Cell Int. 21 , 535 (2021). Wang, L. et al. MiR-210-3p-EphrinA3-PI3K/AKT axis regulates the progression of oral cancer. J. Cell. Mol. Med. 24 , 4011-4022 (2020). Wang, Z., Liu, Z., Liu, B., Liu, G. & Wu, S. Dissecting the roles of Ephrin-A3 in malignant peripheral nerve sheath tumor by TALENs. Oncol. Rep. 34 , 391-398 (2015). Lin, P. & Yang, H. EFNA3 is a prognostic biomarker for the overall survival of patients with hepatocellular carcinoma. J. Hepatol. 77 , 879-880 (2022). Huang, S. et al. A comprehensive prognostic and immunological analysis of ephrin family genes in hepatocellular carcinoma. Front. Mol. Biosci. 9 , 943384 (2022). Winder, M. et al. The application of abbreviated MRI protocols in malignant liver lesions surveillance. Eur. J. Radiol. 164 , 110840 (2023). Wang, C., Yuan, X., Wu, N., Sun, W. & Tian, Y. Optimization of hepatobiliary phase imaging in gadoxetic acid-enhanced magnetic resonance imaging: a narrative review. Quant. Imaging Med. Surg. 13 , 1972-1982 (2023). Ichikawa, S. & Goshima, S. Gadoxetic Acid-Enhanced Liver MRI: Everything You Need to Know. Invest. Radiol. 59 , 53-68 (2024). Chen, Y. et al. Preoperative prediction of cholangiocyte phenotype hepatocellular carcinoma on contrast-enhanced MRI and the prognostic implication after hepatectomy. Insights Imaging . 14 , 190 (2023). Chernyak, V. et al. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma in At-Risk Patients. Radiology . 289 , 816-830 (2018). Wang, X. et al. Clinical-Radiological Characteristic for Predicting Ultra-Early Recurrence After Liver Resection in Solitary Hepatocellular Carcinoma Patients. J. Hepatocell. Carcinoma . 10 , 2323-2335 (2023). Lee, S., Kim, S. H., Lee, J. E., Sinn, D. H. & Park, C. K. Preoperative gadoxetic acid-enhanced MRI for predicting microvascular invasion in patients with single hepatocellular carcinoma. J. Hepatol. 67 , 526-534 (2017). Chen, S. et al. Apatinib plus hepatic arterial infusion of oxaliplatin and raltitrexed for hepatocellular carcinoma with extrahepatic metastasis: phase II trial. Nat. Commun. 15 , 8857 (2024). Zou, B. et al. The Expression of FAP in Hepatocellular Carcinoma Cells is Induced by Hypoxia and Correlates with Poor Clinical Outcomes. J. Cancer . 9 , 3278-3286 (2018). You, R. et al. CPEB2 Suppresses Hepatocellular Carcinoma Epithelial-Mesenchymal Transition and Metastasis through Regulating the HIF-1α/miR-210-3p/CPEB2 Axis. Pharmaceutics . 15 , (2023). Zhuang, Y. et al. Small extracellular vesicles derived from hypoxic mesenchymal stem cells promote vascularized bone regeneration through the miR-210-3p/EFNA3/PI3K pathway. Acta Biomater. 150 , 413-426 (2022). Yu, H. & Shi, G. Cisplatin chemotherapy-induced miRNA-210 signaling inhibits hepatocellular carcinoma cell growth. Transl. Cancer Res. 8 , 626-634 (2019). Ronot, M., Purcell, Y. & Vilgrain, V. Hepatocellular Carcinoma: Current Imaging Modalities for Diagnosis and Prognosis. Dig. Dis. Sci. 64 , 934-950 (2019). Rhee, H. et al. Hepatocellular Carcinoma with Irregular Rim-Like Arterial Phase Hyperenhancement: More Aggressive Pathologic Features. Liver Cancer . 8 , 24-40 (2019). Kadi, D. et al. Imaging prognostication and tumor biology in hepatocellular carcinoma. Journal of liver cancer . 23 , 284-299 (2023). Hwang, Y. J. et al. Classification of microvascular invasion of hepatocellular carcinoma: correlation with prognosis and magnetic resonance imaging. Clin. Mol. Hepatol. 29 , 733-746 (2023). Fowler, K. J. et al. Pathologic, Molecular, and Prognostic Radiologic Features of Hepatocellular Carcinoma. Radiographics: a review publication of the Radiological Society of North America, Inc . 41 , 1611-1631 (2021). Umakoshi, N. et al. Image-Guided Ablation Therapies for Extrahepatic Metastases from Hepatocellular Carcinoma: A Review. Cancers . 15 , (2023). Additional Declarations No competing interests reported. Supplementary Files Supplementalmaterials.pdf Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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02:20:32","extension":"html","order_by":25,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":86947,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7628199/v1/e245a388c33496381f387e86.html"},{"id":93538896,"identity":"7e3c3fe1-8fe3-49dd-a4c0-8dbc9fb5f6c3","added_by":"auto","created_at":"2025-10-15 02:12:31","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1828537,"visible":true,"origin":"","legend":"\u003cp\u003eThe construction and verification process of the nomogram. Abbreviations: OS, overall survival; ROC, receiver operating characteristic; AUC, area under the curve; C-index, concordance index; DCA, decision curve analysis; K-M, Kaplan–Meier.\u003c/p\u003e","description":"","filename":"Figure1.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7628199/v1/f50e920d84f0cee140cf65f3.jpg"},{"id":93538901,"identity":"5f6df5e3-d2d4-4a3d-be27-a023431fc357","added_by":"auto","created_at":"2025-10-15 02:12:31","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":5890698,"visible":true,"origin":"","legend":"\u003cp\u003eForest plots illustrate the key variables identified through univariate and multivariate Cox regression analyses. APHE, arterial phase hyperenhancement; PVP, portal venous phase.\u003c/p\u003e","description":"","filename":"Figure2.tiff.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7628199/v1/9994bf8e77e5a27f276e6616.jpg"},{"id":93539691,"identity":"706bb73b-f4a8-46a2-805e-05052fb36ed0","added_by":"auto","created_at":"2025-10-15 02:20:31","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":899141,"visible":true,"origin":"","legend":"\u003cp\u003e(A) The constructed nomogram. Calibration curves of the nomogram in the training set (B) and validation set (C). APHE, arterial phase hyperenhancement; OS, overall survival.\u003c/p\u003e","description":"","filename":"Figure3.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7628199/v1/272dbcdaa11f23652315d928.jpg"},{"id":93538916,"identity":"7223eaf3-a117-4a24-9e75-9aac241b696b","added_by":"auto","created_at":"2025-10-15 02:12:32","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":4468188,"visible":true,"origin":"","legend":"\u003cp\u003eReceiver operating characteristic curves of the nomogram in the training set (A) and validation set (B). (C) The time-dependent Concordance-index curves. AUC, area under the curve.\u003c/p\u003e","description":"","filename":"Figure4.tiff.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7628199/v1/c0b78fc6ab2bc314b021169e.jpg"},{"id":93538910,"identity":"be256f03-7b8d-4e0c-bfe6-88eaef91df58","added_by":"auto","created_at":"2025-10-15 02:12:31","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":2289263,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan–Meier curves in the training set (A), the validation set (B), and the total patients (C). OS, overall survival.\u003c/p\u003e","description":"","filename":"Figure5.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7628199/v1/b15b5b3880887d344f4564a7.jpg"},{"id":93538904,"identity":"75b48f26-5686-4290-ae01-4ea1ef1e9e71","added_by":"auto","created_at":"2025-10-15 02:12:31","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":7513859,"visible":true,"origin":"","legend":"\u003cp\u003eDecision curve analysis for different survival times (12 months, 36 months, and 60 months) in the training set (A-C) and validation set (D-F).\u003c/p\u003e","description":"","filename":"Figure6.tiff.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7628199/v1/58f45771a2011e8c64dc2d4a.jpg"},{"id":99779446,"identity":"40937de3-9a1d-4451-a32f-7856e9c03995","added_by":"auto","created_at":"2026-01-08 10:24:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":23514141,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7628199/v1/7ea04e64-a161-4af4-9486-20c3fb6d3cc8.pdf"},{"id":93538894,"identity":"0f6d3dda-0eec-494b-bb89-86dd2a1ecb53","added_by":"auto","created_at":"2025-10-15 02:12:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":331916,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementalmaterials.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7628199/v1/e4c8a3ba77ee1f2c48977938.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Construction of a nomogram integrating magnetic resonance imaging features and Ephrin-A3 expression to predict postoperative overall survival in hepatocellular carcinoma","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHepatocellular carcinoma (HCC) ranks among the most common and deadly cancers globally, exhibiting rising incidence and mortality rates\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. China alone reported roughly 410,000 new HCC cases in 2020, accounting for 45.3% of global new cases\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Although various HCC treatments exist, the 5-year survival rate remains low (15\u0026ndash;38%) because most cases are detected at advanced stages, exhibit chemotherapy resistance, and show high rates of recurrence and metastasis\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eEFNA3 is a hypoxia-related gene, and its expression is directly or indirectly regulated by hypoxia-inducible factor-1α (HIF-1α)\u003csup\u003e4\u0026ndash;7\u003c/sup\u003e. Its protein product, ephrin-A3, functions as a cell-surface ligand that binds Eph receptor tyrosine kinases, mediating neuronal, vascular, and epithelial cell migration, repulsion, and adhesion\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. The Eph-ephrin signaling axis contributes to axon guidance and influences critical oncogenic processes, including cancer cell proliferation, invasion, metastasis, and angiogenesis\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. In gastric cancer, elevated EFNA3 mRNA expression correlates with poor prognosis and predicts immunotherapy response\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Wang, Y. et al.\u003csup\u003e10\u003c/sup\u003e identified elevated EFNA3 expression in bladder urothelial carcinoma tissues through bioinformatic analysis and immunohistochemical (IHC) validation. Patients exhibiting high EFNA3 levels demonstrated markedly reduced overall survival (OS). Lung adenocarcinoma tissues show substantial EFNA3 upregulation, where it drives malignancy through enhanced proliferation and glycolysis, correlating inversely with both OS and progression-free survival\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. However, EFNA3 displays tumor-suppressive roles in some contexts. The miR-210-3p-Ephrin-A3 -PI3K/AKT axis suppresses Ephrin-A3 expression to promote oral squamous cell carcinoma progression\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. EFNA3 similarly acts as a tumor suppressor in malignant peripheral nerve sheath tumors\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Although elevated EFNA3 mRNA levels correlate with OS in HCC patients\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e, the IHC expression of Ephrin-A3 has not been reported to predict postoperative OS in HCC patients.\u003c/p\u003e\u003cp\u003eMagnetic Resonance Imaging (MRI) has become an increasingly vital diagnostic tool, offering detailed insights into organ anatomy, physiological function, and metabolic activity. MRI outperforms other imaging modalities in detecting and monitoring liver lesions, owing to its superior soft tissue contrast, diverse scanning sequences, and advanced techniques. These include enhanced data acquisition, refined image reconstruction, improved denoising algorithms, reduced artifacts, and the application of hepatocyte-specific contrast agents\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. Gadolinium ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA) is a liver-specific contrast agent with the highest efficiency in its class and has been widely adopted in clinical practice\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. In addition to providing dynamic contrast-enhanced imaging comparable to conventional extracellular contrast agents, Gd-EOB-DTPA-enhanced MRI offers an additional hepatobiliary phase (HBP), which aids in the detection and characterization of liver lesions as well as the assessment of liver function and fibrosis\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThis study aims to investigate the relationship between Ephrin-A3 expression and postoperative OS in HCC patients and develop a nomogram incorporating clinical, pathological, Gd-EOB-DTPA MRI features, and Ephrin-A3 expression to predict postoperative OS in HCC patients.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eResearch objects\u003c/h2\u003e\u003cp\u003e This retrospective study qualified for exemption from obtaining patient informed consent. The Medical Ethics Committee of the First Affiliated Hospital of Guangxi Medical University granted ethical approval for this study on August 13, 2025 (2025-E0662) following the principles outlined in the Declaration of Helsinki and the Declaration of Istanbul. Patients with HCC who underwent surgical treatment at the First Affiliated Hospital of Guangxi Medical University between February 11, 2018, and January 10, 2020, were enrolled based on the following inclusion and exclusion criteria.\u003c/p\u003e\u003cp\u003eInclusion criteria:\u003c/p\u003e\u003cp\u003e1) Age 18\u0026ndash;80 years;\u003c/p\u003e\u003cp\u003e2) The abdominal Gd-EOB-DTPA MRI enhanced scan was received before the operation;\u003c/p\u003e\u003cp\u003e3) Radical resection within two weeks post-MRI at our center;\u003c/p\u003e\u003cp\u003e4) Histopathologically confirmed HCC.\u003c/p\u003e\u003cp\u003eExclusion criteria:\u003c/p\u003e\u003cp\u003e1) Previous antitumor interventions (embolization, radiotherapy, chemotherapy, ablation, or systemic therapy);\u003c/p\u003e\u003cp\u003e2) Concurrent or prior malignancies;\u003c/p\u003e\u003cp\u003e3) Perioperative death due to severe complications (e.g., cardiac, pulmonary, cerebral, or renal dysfunction) or infection/hemorrhage;\u003c/p\u003e\u003cp\u003e4) Inadequate follow-up documentation;\u003c/p\u003e\u003cp\u003e5) Suboptimal MRI quality.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData collection and follow-up\u003c/h3\u003e\n\u003cp\u003ePatient demographic and clinical data, including sex, age, and Barcelona Clinic Liver Cancer (BCLC) stage, were retrieved from the medical record system. Preoperative laboratory parameters included alpha-fetoprotein (AFP), protein induced by vitamin K absence or antagonist-II (PIVKA-II), hepatitis B virus (HBV)-related markers, albumin (ALB), aspartate aminotransferase (AST), alanine transaminase (ALT), total bilirubin (TBIL), and direct bilirubin (DBIL). Pathological data comprised tumor number, Edmondson-Steiner (ES) grade, Ishak fibrosis score, Ishak inflammation score, microvascular invasion (MVI) grade, and IHC vascular endothelial growth factor (VEGF) expression.\u003c/p\u003e\u003cp\u003eFollow-up commenced on the surgical date, and guided by the AFP levels and imaging results, augmented by telephone interviews. Patients were followed for at least five years postoperatively or until death. The endpoint of this study was OS, defined as the duration from the date of surgery to the date of death or the last follow-up. Patients who could not be contacted during the follow-up period were recorded as lost to follow-up.\u003c/p\u003e\n\u003ch3\u003eMRI acquisition and analysis\u003c/h3\u003e\n\u003cp\u003eMRI examinations were performed with 3.0-T system (Siemens MAGNETOM Prisma, 18-channel body array coil). The MRI sequences included T2-weighted two-dimensional fast spin echo imaging, diffusion-weighted imaging (DWI)(b values: 50,400, and 1000 s/mm2) with apparent diffusion coefficient (ADC) maps, T1-weighted dual gradient-echo in- and opposed-phase imaging, and dynamic T1- weighted three-dimensional gradient-echo imaging before and after injection of gadoxetic acid disodium (Primovist\u0026reg;, Bayer Pharma AG) in the late arterial phase, portal venous phase (60 s), transitional phase (3 minutes), and hepatobiliary phase (20 minutes). The arterial phase images were determined either by the acquisition triggered 7 s after the arrival of the contrast bolus in the celiac trunk or by a multiple arterial phase (MAP) imaging technique. Specifically, the MAP images were acquired with an 18 s breath hold 20 s following the contrast agent injection and further reconstructed with a temporal resolution of 3 s. For dynamic imaging, the contrast agent was injected at a rate of 1\u0026ndash;2 ml/s for a total dose of 0.025 mmol/kg body weight, followed by 20\u0026ndash;30 ml of 0.9% saline flush. Details of the MRI sequences and parameters are shown in Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003eTwo abdominal radiologists (with 5 and 10 years of experience, respectively) independently evaluated all MR images without access to clinical or pathological data. For discordant cases, qualitative imaging features were determined by consensus, whereas quantitative measurements were averaged. Cohen\u0026rsquo;s kappa coefficient evaluated interobserver agreement for categorical variables, and the intraclass correlation coefficient (ICC) assessed consistency for continuous measurements.\u003c/p\u003e\u003cp\u003eDrawing on prior studies\u003csup\u003e\u003cspan additionalcitationids=\"CR20 CR21 CR22\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e, we assessed 23 qualitative and quantitative features, with detailed descriptions provided in Sup. Table S2. The following features are included: tumor size, apparent diffusion coefficient (ADC) value, tumor margin, marked diffusion restriction, marked T2 hyperintensity, intralesional fat, targetoid restriction, targetoid transitional phase (TP) or HBP appearance, nonrim arterial phase hyperenhancement (APHE), internal artery, nonperipheral \"washout\", portal venous phase (PVP) peritumoral hypo-enhancement, tumor capsule, intratumoral hemorrhage, nodule-in-nodule architecture, mosaic architecture, intralesional necrosis, tumor in vein, Peritumoral enhancement on arterial phase (AP), Peritumoral hypointensity on HBP, tumor hypointensity on HBP, extrahepatic metastasis, hemorrhage and necrosis. When multiple lesions were present, the analysis focused on the largest one.\u003c/p\u003e\n\u003ch3\u003eImmunohistochemistry\u003c/h3\u003e\n\u003cp\u003eThe primary antibody is the EFNA3 Rabbit pAb (120597, diluted 1:100; Zheng Neng Biotechnology, Chengdu). Representative images (3\u0026ndash;5 per sample) were captured under a UC90 microscope (Olympus, Japan). The integrated optical density (IOD) and area were quantified using Image-Pro Plus v6.0 software (Media Cybernetics Inc., Bethesda, MD, USA). The averaged optical density (AOD) was calculated by dividing IOD by the area and was used for subsequent analyses\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. The optimal cut-off value of AOD for predicting OS was determined using the surv_cutpoint() function from the survminer package. Based on this cut-off, patients were stratified into high- and low-expression groups.\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eAll statistical analyses were conducted in R (version 4.4.2). For continuous variables, normality was assessed using the Shapiro-Wilk test. Normally distributed data were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) and compared between groups with an independent t-test. Non-normally distributed data were summarized as median [P25, P75] and analyzed using the Mann-Whitney U test for intergroup comparisons. Categorical variables appeared as frequencies (percentages), compared between groups with chi-square tests or Fisher\u0026rsquo;s exact tests when chi-square assumptions were violated. Minor missing values were handled through multiple imputation via the missRange package. Two-tailed tests were applied throughout, with statistical significance set at P\u0026thinsp;\u0026lt;\u0026thinsp;0.05. The construction and verification process of the nomogram was shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eBaseline characteristics\u003c/h2\u003e\u003cp\u003eBetween February 2018 and January 2020, we retrospectively evaluated 200 patients, of whom 152 cases with HCC met the inclusion and exclusion criteria. After excluding 41 cases with incomplete follow-up data, 111 patients (99 male, 12 female) with complete survival records were analyzed. Their mean age was 50.09\u0026thinsp;\u0026plusmn;\u0026thinsp;11.28 years, with a median follow-up of 61 months (range: 3\u0026ndash;69). At the final follow-up, 90 patients (81.1%) remained alive, while 21 (18.9%) had died. The study cohort comprised 100 cases (90.1%) with high EFNA3 expression and 11 cases (9.9%) exhibiting low expression. Interobserver agreement for categorical imaging features, measured by kappa statistics, showed good consistency (κ\u0026thinsp;=\u0026thinsp;0.712\u0026ndash;0.920). For ADC values, the ICC reached 0.705. Sup. Table S3 summarizes the baseline patient characteristics.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eUnivariate and multivariate Cox regression analysis\u003c/h3\u003e\n\u003cp\u003eThe univariate Cox regression analysis conducted on the training set identified EFNA3 expression, PVP peritumoral hypointensity, extrahepatic metastasis, and hemorrhage/necrosis as significant predictors of OS (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). No other clinical or MRI features demonstrated a statistically significant association with OS (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Sup. Table S4). Multivariate Cox regression analysis identified EFNA3 expression, nonrim APHE, margin, and extrahepatic metastasis as independent predictors of OS in HCC patients following curative resection (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The forest plot presents the odds ratios (OR) and 95% confidence intervals (CI) for key variables identified by univariate and multivariate Cox regression analysis (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eConstruction and evaluation of the nomogram\u003c/h2\u003e\u003cp\u003eFigure\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA presents the constructed nomogram for predicting OS in HCC patients. The calibration curves for both training (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB) and validation (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eC) sets showed close agreement between predicted and observed OS probabilities at 12, 36, and 60 months. Time-dependent receiver operating characteristic (ROC) curves yielded AUC values of 0.790, 0.790, and 0.776 at 12, 36, and 60 months in the training set (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eA), while the validation set (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eB) exhibited values of 0.970, 0.737, and 0.770, respectively. The model achieved a concordance index (C-index) of 0.76 in the training set and 0.72 in the validation set. Figure\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eC illustrates that the C-indexes remained elevated during early follow-up for both cohorts, reflecting stronger discriminative capacity for short-term survival predictions. While the C-index gradually decreased over time, it consistently exceeded 0.7, maintaining clinically meaningful predictive accuracy throughout extended follow-up.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eUsing an optimal nomogram score cut-off of 67.020, patients were stratified into low- and high-risk groups. Kaplan-Meier survival curves revealed significantly prolonged OS in the low-risk group across the training set (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eA), validation set (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eB), and total patients (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eC) (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Decision curve analysis (DCA) demonstrated clinical utility for the model in the training set, with net benefit across threshold probabilities of 0.1\u0026ndash;0.5 (12-month), 0.1\u0026ndash;0.9 (36-month), and 0.1\u0026ndash;0.9 (60-month). In the validation set, the model provided net benefit only for 36- and 60-month predictions (thresholds 0.1\u0026ndash;0.9), with no significant benefit at 12 months (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eEphrin-A3, margin, nonrim APHE, and extrahepatic metastasis independently predicted postoperative OS in HCC patients. High Ephrin-A3 expression, smooth tumor margins, nonrim APHE, and the absence of extrahepatic metastasis correlated with prolonged OS. The nomogram incorporating these factors achieved strong predictive accuracy. The validation set yielded an AUC of 0.970 for 12-month predictions, yet DCA revealed no clinical benefit during this period, likely due to the limited number of patients with 12-month OS in the validation cohort.\u003c/p\u003e\u003cp\u003eHusain et al. found that HIF-1α directly upregulates EFNA3 expression under hypoxic conditions, with both EFNA3 and Ephrin-A3 protein driving HCC initiation, growth, stemness, and migration\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. G\u0026oacute;mez-Maldonado et al.\u003csup\u003e6\u003c/sup\u003e reported stable EFNA3 mRNA levels during hypoxia but identified HIF-mediated expression of a novel long non-coding RNA from the EFNA3 locus that increased Ephrin-A3 protein accumulation. Fasanaro et al.\u003csup\u003e7\u003c/sup\u003e observed decreased Ephrin-A3 protein expression under hypoxia despite elevated mRNA levels, implicating miR-210-mediated post-transcriptional regulation. While public mRNA databases associate high EFNA3 expression with reduced OS\u003csup\u003e14,15\u003c/sup\u003e, our data align with Fasanaro et al.\u0026rsquo;s results, showing prolonged OS in high-Ephrin-A3 protein expression cases.\u003c/p\u003e\u003cp\u003eThe hypoxia-responsive miR-210 enhances angiogenesis, metastasis, and tumor progression across malignancies\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. HIF-1α-induced miR-210 overexpression suppresses Ephrin-A3 while activating the PI3K/AKT pathway\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e, stimulating endothelial cell proliferation, migration, and angiogenesis. In oral cancer, Ephrin-A3 drives epithelial-mesenchymal transition through PI3K/AKT signaling, accelerating tumor growth, invasion, metastasis, and drug resistance\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. HCC cells exhibit miR-210-mediated Ephrin-A3 downregulation, whereas cisplatin treatment upregulates Ephrin-A3 and improves chemosensitivity\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. Ephrin-A3 overexpression increases phosphorylated focal adhesion kinase and tumor necrosis factor-alpha, while reducing PI3K, GTPase, integrins, VEGF, and HIF-1α, suggesting tumor suppression through focal adhesion kinase signaling modulation and VEGF-dependent angiogenesis\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eTypical HCC exhibits nonrimAPHE. Approximately 40% of HCC cases may lack this feature, particularly in very early-stage or poorly differentiated tumors\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. Rim APHE, marked by peripheral enhancement, correlates with aggressive histopathological characteristics such as hypoxic and fibrotic microenvironments and elevated stemness\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. Tumors with smooth margins are often histologically encapsulated and exhibit a lower frequency of invasion into the surrounding liver parenchyma\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e. In contrast, tumors with irregular margins demonstrate a higher incidence of MVI and are associated with poorer 5-year OS and recurrence-free survival\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. Radiologically, irregular margins often reflect invasive growth, tumor in vein, and extrahepatic metastases\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e. The most frequent extrahepatic metastatic sites are the lungs, intra-abdominal lymph nodes, bones, and adrenal glands, with possible spread to the pleura, peritoneum, and brain. These patients face a dismal prognosis, with a 5-year survival rate of just 3%\u003csup\u003e33\u003c/sup\u003e. In this study, smooth tumor margins, nonrim APHE, and the absence of extrahepatic metastasis correlated with prolonged OS, aligning with previous findings.\u003c/p\u003e\u003cp\u003eThis study has several limitations. First, due to its retrospective nature, unavoidable selection bias exists, necessitating prospective randomized controlled trials with multiple-group comparisons to mitigate this bias. Second, the insufficient sample size and lack of external validation may affect the model's generalizability, future studies will expand the sample size and conduct external validation to verify the results. Potentially due to the small sample size and selection bias, pathological ES grading, staging, MVI, and other factors that may correlate with OS showed no significant association with OS in this study. Finally, the potential influence of other postoperative treatment modalities in HCC patients cannot be excluded.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eEphrin-A3, margin, nonrim APHE, and extrahepatic metastasis independently predicted postoperative OS in HCC patients. High Ephrin-A3 IHC expression, smooth tumor margins, nonrim APHE, and the absence of extrahepatic metastasis correlated with prolonged OS. The nomogram incorporating these factors showed good predictive accuracy for postoperative OS in HCC. These findings provide valuable insights for prognostic assessment and therapeutic decision-making in HCC patients.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eADC, Apparent Diffusion Coefficient; AFP, alpha-fetoprotein; ALB, albumin; ALT, alanine transaminase; AOD, averaged optical density; AP, arterial phase; APHE, arterial phase hyperenhancement; AST, aspartate aminotransferase; AUC, area under the curve; BCLC, Barcelona Clinic Liver Cancer; C-index, concordance index; DBIL, direct bilirubin; DCA, decision curve analysis; DWI, diffusion-weighted imaging; ES, Edmondson-Steiner; Gd-EOB-DTPA, gadolinium ethoxybenzyl-diethylenetriamine pentaacetic acid; HBP, hepatobiliary phase; HCC, hepatocellular carcinoma; HIF-1\u0026alpha;, hypoxia-inducible factor-1\u0026alpha;; ICC, intraclass correlation coefficient; IHC, immunohistochemical; IP, in-phase; K-M, Kaplan-Meier; MRI, Magnetic Resonance Imaging; MVI, microvascular invasion; OP, opposed-phase; OS, overall survival; PIVKA-II, protein induced by vitamin K absence or antagonist-II; PVP, portal venous phase; ROC, receiver operating characteristic; TBIL, total bilirubin; TP, transitional phase；VEGF, vascular endothelial growth factor.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCompeting interest\u003c/strong\u003e\u003cp\u003eThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003cp\u003eThe Medical Ethics Committee of the First Affiliated Hospital of Guangxi Medical University granted ethical approval for this study on August 13, 2025 (2025-E0662) following the principles outlined in the Declaration of Helsinki and the Declaration of Istanbul.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003cp\u003e Written informed consent was waived by the Institutional Review Board due to the retrospective nature of the study.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis study was supported by the Open Project of NHC Key Laboratory of Thalassemia Medicine (NO. GJWJWDP202208) and National Natural Science Foundation of China, Grant/Award Number: 82060310.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eY.Z., L.F., Q.C., S.T., and W.H. collected and analyzed the data and prepared the visualizations. Y.Z. wrote the initial draft of the manuscript. L.L. reviewed and edited the manuscript, supervised the study, acquired funding, and developed the conceptual framework. All authors critically evaluated and approved the final version.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe sincerely thank all colleagues and institutions that contributed to this study.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data supporting this study's findings are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eJohnson, P., Zhou, Q., Dao, D. Y. \u0026amp; Lo, Y. M. D. Circulating biomarkers in the diagnosis and management of hepatocellular carcinoma. \u003cem\u003eNature reviews. Gastroenterology \u0026amp; hepatology\u003c/em\u003e. \u003cstrong\u003e19\u003c/strong\u003e, 670-681 (2022).\u003c/li\u003e\n\u003cli\u003eXie, D., Shi, J., Zhou, J., Fan, J. \u0026amp; Gao, Q. Clinical practice guidelines and real-life practice in hepatocellular carcinoma: A Chinese perspective. \u003cem\u003eClin. Mol. Hepatol.\u003c/em\u003e \u003cstrong\u003e29\u003c/strong\u003e, 206-216 (2023).\u003c/li\u003e\n\u003cli\u003eOura, K., Morishita, A., Tani, J. \u0026amp; Masaki, T. Tumor Immune Microenvironment and Immunosuppressive Therapy in Hepatocellular Carcinoma: A Review. \u003cem\u003eInternational journal of molecular sciences\u003c/em\u003e. \u003cstrong\u003e22\u003c/strong\u003e, 5801 (2021).\u003c/li\u003e\n\u003cli\u003eMo, Z., Liu, D., Rong, D. \u0026amp; Zhang, S. Hypoxic Characteristic in the Immunosuppressive Microenvironment of Hepatocellular Carcinoma. \u003cem\u003eFront. Immunol.\u003c/em\u003e \u003cstrong\u003e12\u003c/strong\u003e, 611058 (2021).\u003c/li\u003e\n\u003cli\u003eHusain, A. et al. Ephrin-A3/EphA2 axis regulates cellular metabolic plasticity to enhance cancer stemness in hypoxic hepatocellular carcinoma. \u003cem\u003eJ. Hepatol.\u003c/em\u003e \u003cstrong\u003e77\u003c/strong\u003e, 383-396 (2022).\u003c/li\u003e\n\u003cli\u003eG\u0026oacute;mez-Maldonado, L. et al. EFNA3 long noncoding RNAs induced by hypoxia promote metastatic dissemination. \u003cem\u003eOncogene\u003c/em\u003e. \u003cstrong\u003e34\u003c/strong\u003e, 2609-2620 (2015).\u003c/li\u003e\n\u003cli\u003eFasanaro, P. et al. MicroRNA-210 modulates endothelial cell response to hypoxia and inhibits the receptor tyrosine kinase ligand Ephrin-A3. \u003cem\u003eThe Journal of biological chemistry\u003c/em\u003e. \u003cstrong\u003e283\u003c/strong\u003e, 15878-15883 (2008).\u003c/li\u003e\n\u003cli\u003eChen, J. Regulation of tumor initiation and metastatic progression by Eph receptor tyrosine kinases. \u003cem\u003eAdv. Cancer. Res.\u003c/em\u003e \u003cstrong\u003e114\u003c/strong\u003e, 1-20 (2012).\u003c/li\u003e\n\u003cli\u003eZheng, P. et al. EFNA3 Is a Prognostic Biomarker Correlated With Immune Cell Infiltration and Immune Checkpoints in Gastric Cancer. \u003cem\u003eFront. Genet.\u003c/em\u003e \u003cstrong\u003e12\u003c/strong\u003e, 796592 (2021).\u003c/li\u003e\n\u003cli\u003eWang, Y. et al. Clinicopathological and prognostic significance of Ephrin A3 in bladder urothelial carcinoma. \u003cem\u003eOncol. Lett.\u003c/em\u003e \u003cstrong\u003e26\u003c/strong\u003e, 524 (2023).\u003c/li\u003e\n\u003cli\u003eDeng, M. et al. EFNA3 as a predictor of clinical prognosis and immune checkpoint therapy efficacy in patients with lung adenocarcinoma. \u003cem\u003eCancer Cell Int.\u003c/em\u003e \u003cstrong\u003e21\u003c/strong\u003e, 535 (2021).\u003c/li\u003e\n\u003cli\u003eWang, L. et al. MiR-210-3p-EphrinA3-PI3K/AKT axis regulates the progression of oral cancer. \u003cem\u003eJ. Cell. Mol. Med.\u003c/em\u003e \u003cstrong\u003e24\u003c/strong\u003e, 4011-4022 (2020).\u003c/li\u003e\n\u003cli\u003eWang, Z., Liu, Z., Liu, B., Liu, G. \u0026amp; Wu, S. Dissecting the roles of Ephrin-A3 in malignant peripheral nerve sheath tumor by TALENs. \u003cem\u003eOncol. Rep.\u003c/em\u003e \u003cstrong\u003e34\u003c/strong\u003e, 391-398 (2015).\u003c/li\u003e\n\u003cli\u003eLin, P. \u0026amp; Yang, H. EFNA3 is a prognostic biomarker for the overall survival of patients with hepatocellular carcinoma. \u003cem\u003eJ. Hepatol.\u003c/em\u003e \u003cstrong\u003e77\u003c/strong\u003e, 879-880 (2022).\u003c/li\u003e\n\u003cli\u003eHuang, S. et al. A comprehensive prognostic and immunological analysis of ephrin family genes in hepatocellular carcinoma. \u003cem\u003eFront. Mol. Biosci.\u003c/em\u003e \u003cstrong\u003e9\u003c/strong\u003e, 943384 (2022).\u003c/li\u003e\n\u003cli\u003eWinder, M. et al. The application of abbreviated MRI protocols in malignant liver lesions surveillance. \u003cem\u003eEur. J. Radiol.\u003c/em\u003e \u003cstrong\u003e164\u003c/strong\u003e, 110840 (2023).\u003c/li\u003e\n\u003cli\u003eWang, C., Yuan, X., Wu, N., Sun, W. \u0026amp; Tian, Y. Optimization of hepatobiliary phase imaging in gadoxetic acid-enhanced magnetic resonance imaging: a narrative review. \u003cem\u003eQuant. Imaging Med. Surg.\u003c/em\u003e \u003cstrong\u003e13\u003c/strong\u003e, 1972-1982 (2023).\u003c/li\u003e\n\u003cli\u003eIchikawa, S. \u0026amp; Goshima, S. Gadoxetic Acid-Enhanced Liver MRI: Everything You Need to Know. \u003cem\u003eInvest. Radiol.\u003c/em\u003e \u003cstrong\u003e59\u003c/strong\u003e, 53-68 (2024).\u003c/li\u003e\n\u003cli\u003eChen, Y. et al. Preoperative prediction of cholangiocyte phenotype hepatocellular carcinoma on contrast-enhanced MRI and the prognostic implication after hepatectomy. \u003cem\u003eInsights Imaging\u003c/em\u003e. \u003cstrong\u003e14\u003c/strong\u003e, 190 (2023).\u003c/li\u003e\n\u003cli\u003eChernyak, V. et al. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma in At-Risk Patients. \u003cem\u003eRadiology\u003c/em\u003e. \u003cstrong\u003e289\u003c/strong\u003e, 816-830 (2018).\u003c/li\u003e\n\u003cli\u003eWang, X. et al. Clinical-Radiological Characteristic for Predicting Ultra-Early Recurrence After Liver Resection in Solitary Hepatocellular Carcinoma Patients. \u003cem\u003eJ. Hepatocell. Carcinoma\u003c/em\u003e. \u003cstrong\u003e10\u003c/strong\u003e, 2323-2335 (2023).\u003c/li\u003e\n\u003cli\u003eLee, S., Kim, S. H., Lee, J. E., Sinn, D. H. \u0026amp; Park, C. K. Preoperative gadoxetic acid-enhanced MRI for predicting microvascular invasion in patients with single hepatocellular carcinoma. \u003cem\u003eJ. Hepatol.\u003c/em\u003e \u003cstrong\u003e67\u003c/strong\u003e, 526-534 (2017).\u003c/li\u003e\n\u003cli\u003eChen, S. et al. Apatinib plus hepatic arterial infusion of oxaliplatin and raltitrexed for hepatocellular carcinoma with extrahepatic metastasis: phase II trial. \u003cem\u003eNat. Commun.\u003c/em\u003e \u003cstrong\u003e15\u003c/strong\u003e, 8857 (2024).\u003c/li\u003e\n\u003cli\u003eZou, B. et al. The Expression of FAP in Hepatocellular Carcinoma Cells is Induced by Hypoxia and Correlates with Poor Clinical Outcomes. \u003cem\u003eJ. Cancer\u003c/em\u003e. \u003cstrong\u003e9\u003c/strong\u003e, 3278-3286 (2018).\u003c/li\u003e\n\u003cli\u003eYou, R. et al. CPEB2 Suppresses Hepatocellular Carcinoma Epithelial-Mesenchymal Transition and Metastasis through Regulating the HIF-1\u0026alpha;/miR-210-3p/CPEB2 Axis. \u003cem\u003ePharmaceutics\u003c/em\u003e. \u003cstrong\u003e15\u003c/strong\u003e, (2023).\u003c/li\u003e\n\u003cli\u003eZhuang, Y. et al. Small extracellular vesicles derived from hypoxic mesenchymal stem cells promote vascularized bone regeneration through the miR-210-3p/EFNA3/PI3K pathway. \u003cem\u003eActa Biomater.\u003c/em\u003e \u003cstrong\u003e150\u003c/strong\u003e, 413-426 (2022).\u003c/li\u003e\n\u003cli\u003eYu, H. \u0026amp; Shi, G. Cisplatin chemotherapy-induced miRNA-210 signaling inhibits hepatocellular carcinoma cell growth. \u003cem\u003eTransl. Cancer Res.\u003c/em\u003e \u003cstrong\u003e8\u003c/strong\u003e, 626-634 (2019).\u003c/li\u003e\n\u003cli\u003eRonot, M., Purcell, Y. \u0026amp; Vilgrain, V. Hepatocellular Carcinoma: Current Imaging Modalities for Diagnosis and Prognosis. \u003cem\u003eDig. Dis. Sci.\u003c/em\u003e \u003cstrong\u003e64\u003c/strong\u003e, 934-950 (2019).\u003c/li\u003e\n\u003cli\u003eRhee, H. et al. Hepatocellular Carcinoma with Irregular Rim-Like Arterial Phase Hyperenhancement: More Aggressive Pathologic Features. \u003cem\u003eLiver Cancer\u003c/em\u003e. \u003cstrong\u003e8\u003c/strong\u003e, 24-40 (2019).\u003c/li\u003e\n\u003cli\u003eKadi, D. et al. Imaging prognostication and tumor biology in hepatocellular carcinoma. \u003cem\u003eJournal of liver cancer\u003c/em\u003e. \u003cstrong\u003e23\u003c/strong\u003e, 284-299 (2023).\u003c/li\u003e\n\u003cli\u003eHwang, Y. J. et al. Classification of microvascular invasion of hepatocellular carcinoma: correlation with prognosis and magnetic resonance imaging. \u003cem\u003eClin. Mol. Hepatol.\u003c/em\u003e \u003cstrong\u003e29\u003c/strong\u003e, 733-746 (2023).\u003c/li\u003e\n\u003cli\u003eFowler, K. J. et al. Pathologic, Molecular, and Prognostic Radiologic Features of Hepatocellular Carcinoma. \u003cem\u003eRadiographics: a review publication of the Radiological Society of North America, Inc\u003c/em\u003e. \u003cstrong\u003e41\u003c/strong\u003e, 1611-1631 (2021).\u003c/li\u003e\n\u003cli\u003eUmakoshi, N. et al. Image-Guided Ablation Therapies for Extrahepatic Metastases from Hepatocellular Carcinoma: A Review. \u003cem\u003eCancers\u003c/em\u003e. \u003cstrong\u003e15\u003c/strong\u003e, (2023).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Hepatocellular carcinoma, Hypoxia, MRI, Overall survival, EFNA3","lastPublishedDoi":"10.21203/rs.3.rs-7628199/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7628199/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis study aimed to explore the relationship between Ephrin-A3 expression and postoperative overall survival (OS) in hepatocellular carcinoma (HCC) patients and to develop a prognostic nomogram integrating clinical, pathological, MRI features, and Ephrin-A3 expression. We conducted a retrospective analysis of 111 HCC patients, from whom clinical, pathological, and MRI data were collected, and Ephrin-A3 immunohistochemistry was performed. Using an optimal cut-off value of averaged optical density (AOD) derived from Ephrin-A3 staining to predict OS, patients were categorized into high and low expression groups. The cohort was randomly split into training (70%) and validation (30%) sets. Univariate and multivariate Cox regression analyses identified Ephrin-A3 expression, tumor margin, nonrim arterial phase hyperenhancement, and extrahepatic metastasis as independent predictors of OS. A nomogram was subsequently developed to predict postoperative OS. The model demonstrated concordance indexes of 0.76 and 0.72 in the training and validation sets, respectively. The area under the curve (AUC) values for predicting 12-, 36-, and 60-month OS were 0.790, 0.790, and 0.776 in the training set, and 0.970, 0.737, and 0.770 in the validation set. Kaplan\u0026ndash;Meier survival analysis confirmed significantly longer OS in the low-risk group in both datasets. Calibration curves indicated strong agreement between predicted and observed survival probabilities, and decision curve analysis (DCA) confirmed the clinical utility of the model. In conclusion, Ephrin-A3 serves as an independent prognostic factor for OS in HCC patients after surgery, and the constructed nomogram exhibits favorable predictive performance for postoperative survival.\u003c/p\u003e","manuscriptTitle":"Construction of a nomogram integrating magnetic resonance imaging features and Ephrin-A3 expression to predict postoperative overall survival in hepatocellular carcinoma","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-15 02:12:26","doi":"10.21203/rs.3.rs-7628199/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7823aed2-4ba2-424b-9959-a46637868889","owner":[],"postedDate":"October 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":56147991,"name":"Health sciences/Biomarkers"},{"id":56147992,"name":"Biological sciences/Cancer"},{"id":56147993,"name":"Health sciences/Oncology"}],"tags":[],"updatedAt":"2026-01-08T10:23:23+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-15 02:12:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7628199","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7628199","identity":"rs-7628199","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}