Immune-Excluded CD4⁺ and CD8⁺ T-Cell Depletion Predicts Early Recurrence in Hepatocellular Carcinoma with Microvascular Invasion

Abstract

Background: Early recurrence within six months after resection continues to pose a major clinical challenge in hepatocellular carcinoma (HCC) patients, occurring in approximately 31.9% of patients. This study aims to investigate whether reduced immune cell infiltration across intratumoral and peritumoral compartments is associated with early HCC recurrence in patients with high angiogenic activity and microvascular invasion (MVI). Methods:  A multicenter nested case–control study was conducted using liver tissue samples from 49 patients with HCC who underwent surgical resection. Clinical data were retrieved from medical records. Pathological and immunological parameters were assessed using hematoxylin–eosin (H&E) staining for tumor-infiltrating lymphocytes (TILs) and immunohistochemistry for VEGF, CD4, CD8, and regulatory T cells. The analytical approach included ROC curve analysis, Kaplan-Meier survival estimation, and multivariate Cox regression. Results: Early recurrence occurred in 11 of 49 patients, all showing high VEGF and most with microvascular invasion. Patients with early recurrence had markedly lower intratumoral CD4⁺ T-cell density and reduced peritumoral CD8⁺ T-cell density, while peritumoral CD4⁺ and overall TILs remained higher than intratumoral. Multivariable analysis identified low intratumoral CD4⁺ (HR 7.98; 95% CI: 1.63–39.07) and decreased peritumoral CD8⁺ (HR 4.98; 95% CI: 1.14–21.70) as independent predictors. Intratumoral and peritumoral Treg densities showed no significant association. Conclusions: Low intratumoral CD4⁺ and peritumoral CD8⁺ infiltration were identified as independent predictors of early HCC recurrence, reflecting an immune-excluded tumor phenotype characterized by high peritumoral CD4⁺ and TILs. In this context, angiogenesis-driven stromal and vascular barriers impede effective T-cell trafficking into the tumor core, facilitating early recurrence, particularly in tumors with microvascular invasion. These findings underscore the need for intensified post-resection surveillance and may define a high-risk subgroup for future evaluation of adjuvant therapies.