: The Risk Estimation of Tumor Recurrence After Transplant (RETREAT) score has been previously validated as a prognostic model for post-transplant recurrence. Our objective was to establish the validity of the RETREAT score in an Egyptian cohort.

: The study included 113 patients who underwent living donor liver transplantation (LDLT) for Hepatocellular carcinoma (HCC) between 2004 and 2023. RETREAT score effectiveness was investigated following stratification of patients according to Milan criteria (MC) status on the explant pathology. Recurrence risks were assessed using the Kaplan–Meier analysis and differences were calculated with log-rank test.

: Over a median follow-up duration of 37 months, the cumulative HCC recurrence rates were 15.4%, 24.8%, and 29.5% at 2, 5, and 10 years, respectively. A strong correlation was demonstrated between higher RETREAT scores and increased recurrence risk. Patients with a RETREAT score ≥ 3 (n = 48) experienced significantly higher recurrence rates at 2, 5, and 10 years than those with a RETREAT score ≤ 2 (n = 65) (35.4%, 58.8%, and 70.6% vs 2.2% (p < 0.0001)). Based on explant, 74 patients were identified as meeting the MC. The most favorable outcomes were observed in patients who were both within MC and had a low RETREAT score (n = 51), with no HCC recurrence risk being observed at 2, 5, or 10 years.

: We validated the predictive accuracy of RETREAT score in HCC recurrence post LT. Patients with low RETREAT scores demonstrated a low risk of HCC recurrence, especially those confirmed to be within MC on explant analysis.