Abstract
Effective classification methods and prognostic models enable more accurate classification and treatment of hepatocellular carcinoma (HCC) patients. However, the weak correlation between RNA and protein data has limited the clinical utility of previous RNA-based prognostic models for HCC. In this work, we constructed a novel prognostic framework for HCC patients using seven differentially expressed proteins associated with ferroptosis and iron metabolism. Furthermore, this prognostic model robustly classifies HCC patients into three clinically relevant risk groups. Significant differences in overall survival, age, tumor differentiation, microvascular invasion, distant metastasis, and alpha-fetoprotein levels were observed among the risk groups. Based on the prognostic model and known biological pathways, we explored the potential mechanisms underlying the inconsistent differential expression patterns of FTH1 (Ferritin heavy chain 1) mRNA and protein. Our findings demonstrated that tumor tissues in HCC patients promote liver cancer progression by downregulating FTH1 protein expression, rather than upregulating FTH1 mRNA expression, ultimately leading to poor prognosis. Subsequently, based on risk score and tumor size, we developed a nomogram for predicting the prognosis of HCC patients, which demonstrated superior predictive performance in both the training and validation cohorts (C-index: 0.774; AUC for 1-5 years: 0.783-0.964). Additionally, our findings demonstrated that the adverse prognosis of high-risk HCC patients was closely correlated with ferroptosis in liver cancer tissues, alterations in iron metabolism, and changes in the tumor immune microenvironment. In conclusion, our prognostic model and predictive nomogram offer novel insights and tools for the effective classification of HCC patients, potentially enhancing clinical decision-making and outcomes.