Background: Primary hepatocellular carcinoma (HCC) is a prevalent and aggressive malignancy with a high mortality rate. Transarterial chemoembolisation (TACE) is a widely used non-surgical treatment, but post-procedural recurrence remains a major challenge. Magnetic resonance imaging (MRI) offers a detailed assessment of tumor morphology and perfusion, while serum Protein Induced by Vitamin K Absence or Antagonist-II (PIVKA-II) has emerged as a sensitive HCC-specific biomarker. This study focused on analyzing the predictive value of preoperative MRI combined with serum PIVKA-II for recurrence after TACE in primary HCC.

Methods: A total of 101 patients with primary HCC undergoing TACE between January 2018 and March 2021 were enrolled. Patients were divided into a recurrence group (n = 52) and a non-recurrence group (n = 49), followed by comparison of MRI parameters and serum PIVKA-II levels. Variables demonstrating significant differences underwent logistic regression analysis, and the diagnostic value of the parameters with significant differences was dissected using a receiver operating characteristic (ROC) curve area under the curve (AUC).

Results: Compared with the non-recurrence group, the recurrence group exhibited a higher proportion of localized protrusions and diffuse “target sign”, lower arterial phase values, portal venous phase values, and arterial phase enhancement rates, and higher PIVKA-II levels (p < 0.05). Logistic regression analysis revealed statistically significant differences in arterial phase values, portal venous phase values, and PIVKA-II levels (p < 0.05). ROC curves demonstrated AUC values of 0.872, 0.766, 0.895, and 0.939 for arterial phase values, portal venous phase values, PIVKA-II levels, and combined prediction of post-TACE recurrence in primary HCC, respectively (p < 0.05).

Conclusions: Preoperative MRI combined with serum PIVKA-II testing holds significant predictive value for post-TACE recurrence in patients with primary HCC. Low arterial- and portal venous-phase enhancement values, together with elevated serum PIVKA-II levels, were identified as independent risk factors for recurrence. The combined use of these parameters can improve the accuracy of recurrence prediction, providing a basis for individualized postoperative management and follow-up strategies to optimize patient outcomes.