Retrospective Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Apr 21, 2020; 26(15): 1805-1819
Published online Apr 21, 2020. doi: 10.3748/wjg.v26.i15.1805
Validation of the six-and-twelve criteria among patients with hepatocellular carcinoma and performance score 1 receiving transarterial chemoembolization
Zhe-Xuan Wang, Jing Li, En-Xin Wang, Dong-Dong Xia, Wei Bai, Qiu-He Wang, Jie Yuan, Xiao-Mei Li, Jing Niu, Zhan-Xin Yin, Jie-Lai Xia, Dai-Ming Fan, Guo-Hong Han
Zhe-Xuan Wang, Jing Li, En-Xin Wang, Dong-Dong Xia, Wei Bai, Qiu-He Wang, Jie Yuan, Xiao-Mei Li, Jing Niu, Zhan-Xin Yin, Dai-Ming Fan, Guo-Hong Han, Department of Liver Disease and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an 710032, Shaanxi Province, China
Jie-Lai Xia, Department of Health Statistics, Fourth Military Medical University, Xi’an 710032, Shaanxi Province, China
Author contributions: Wang ZX, Li J and Wang EX contributed equally to this work; Wang ZX, Wang EX and Han GH designed research; Wang ZX, Wang EX, Xia DD and Bai W performed research and collected data; Wang ZX, Li J and Wang EX analyzed data; Xia DD and Xia JL contributed to statistical support; Wang ZX, Li J, Xia DD, Bai W, Wang EX, Wang QH, Yuan J, Li XM, Niu J, Yin ZX, Xia JL, Fan DM and Han GH contributed to administrative, technical or material support; Wang ZX, Li J, Wang EX and Han GH wrote the paper.
Institutional review board statement: The study protocol was reviewed and approved by the institutional Ethics Committees of the First Affiliated Hospital of the Fourth Military Medical University.
Informed consent statement: Patients were not required to give informed consent for this study because the analysis used anonymous clinical data that were obtained after each patient agreed to treatment by written consent.
Conflict-of-interest statement: The authors have no conflict of interest to disclose.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Guo-Hong Han, MD, PhD, Professor, Department of Liver Disease and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, 15 West Changle Road, Xi’an 710032, Shaanxi Province, China. hangh@fmmu.edu.cn
Received: December 12, 2019
Peer-review started: December 12, 2019
First decision: January 7, 2020
Revised: March 13, 2020
Accepted: March 27, 2020
Article in press: March 27, 2020
Published online: April 21, 2020
Processing time: 129 Days and 22.8 Hours
Abstract
BACKGROUND

Transarterial chemoembolization (TACE) is recommended for patients with intermediate hepatocellular carcinoma (HCC) according to treatment guidelines. However, a large number of patients with advanced HCC also receive TACE in clinical practice, especially for those with liver-confined HCC and Eastern Cooperative Oncology Group score (ECOG) 1. In view of previous studies, such patients have different prognoses from advanced HCC patients with macrovascular invasion or extrahepatic spread; therefore, patients with ECOG 1 alone might be classified into the intermediate stage and benefit from TACE treatment, but a study particularly focusing on such patients and exploring the effectiveness of TACE therapy is lacking.

AIM

To investigate treatment outcomes of TACE in HCC patients with ECOG 1 alone and propose a specific prognostic model.

METHODS

Patients from 24 Chinese tertiary hospitals were selected in this nationwide multicenter observational study from January 2010 to May 2016. Overall survival (OS) was estimated using Kaplan–Meier curves and compared by the log-rank test. Multivariate Cox regression was used to develop the potential prognostic models. The discriminatory ability of the models was compared and validated in various patient subgroups. The individual survival prediction for six-and-twelve (6&12) criteria, defined as the algebraic sum of tumor size (cm) and tumor number, was illustrated by contour plot of 3-year survival probability and nomogram.

RESULTS

A total of 792 eligible patients were included. During follow-up, median OS reached 18.9 mo [95% confidence interval (CI): 16.9-21.0]. Three independent multivariate analyses demonstrated that tumor size, tumor number, α-fetoprotein level, albumin–bilirubin grade and total bilirubin were prognostic factors of OS (P < 0.05). The previously proposed 6&12 criteria was comparable or even better than currently proposed with the highest predictive ability. In addition, the 6&12 criteria was correlated with OS in various subgroups of patients. The patients were stratified into three strata with score ≤ 6, > 6 but ≤ 12, and > 12 with different median OS of 39.8 mo (95%CI: 23.9-55.7), 21.1 mo (95%CI: 18.4-23.8) and 9.8 mo (95%CI: 8.3-11.3), respectively (P < 0.001).

CONCLUSION

TACE is effective for advanced HCC patients with ECOG 1 alone, and the 6&12 criteria may help with clinical decision-making.

Keywords: Transarterial chemoembolization; Hepatocellular carcinoma; Overall survival; Predictive factors; Prognostic model; Risk stratification

Core tip: According to the current treatment guidelines, patients with liver-confined hepatocellular carcinoma and Eastern Cooperative Oncology Group score of 1 alone should be classified as advanced stage and treated with systemic therapy. However, transarterial chemoembolization is commonly used for this group of patients in clinical practice. The current study retrospectively included 792 eligible patients from 24 Chinese tertiary hospitals and found transarterial chemoembolization was effective for hepatocellular carcinoma patients with Eastern Cooperative Oncology Group score of 1 alone, and the “six-and-twelve criteria”, defined as the algebraic sum of tumor size (cm) and tumor number, might help the risk stratification and survival prediction.