Retrospective Study
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jan 14, 2021; 27(2): 189-207
Published online Jan 14, 2021. doi: 10.3748/wjg.v27.i2.189
Development of a computed tomography-based radiomics nomogram for prediction of transarterial chemoembolization refractoriness in hepatocellular carcinoma
Xiang-Ke Niu, Xiao-Feng He
Xiang-Ke Niu, Xiao-Feng He, Department of Interventional Radiology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong Province, China
Xiang-Ke Niu, Department of Interventional Radiology, Affiliated Hospital of Chengdu University, Chengdu 610081, Sichuan Province, China
Author contributions: He XF designed the research study; He XF and Niu XK performed the research; Niu XK analyzed the data; Niu XK and He XF wrote the paper; all authors have read and approved the final manuscript.
Supported by Health and Family Planning Commission of Sichuan Province, China, No. 17PJ430 and No. 18PJ150.
Institutional review board statement: This study was reviewed and approved by the Ethics Committee of Affiliated Hospital of Chengdu University, approval No. PJ2019-019-01.
Informed consent statement: Patients were not required to give informed consent to the study because the analysis used anonymous data that were obtained after each patient agreed to treatment by written consent.
Conflict-of-interest statement: The authors declare that there is no conflict of interest related to this study.
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:
Corresponding author: Xiao-Feng He, MD, Chief Doctor, Professor, Department of Interventional Radiology, Nanfang Hospital, Southern Medical University, No. 1838 North Guangzhou Avenue, Guangzhou 510515, Guangdong Province, China.
Received: November 2, 2020
Peer-review started: November 2, 2020
First decision: December 3, 2020
Revised: December 7, 2020
Accepted: December 16, 2020
Article in press: December 16, 2020
Published online: January 14, 2021

Some patients with hepatocellular carcinoma (HCC) are more likely to experience disease progression despite continuous transarterial chemoembolization (TACE), which is called TACE refractoriness. At present, it is still difficult to predict TACE refractoriness, although some models/scoring systems have been developed. At present, radiological-based radiomics models have been successfully applied to predict cancer patient prognosis.


To develop and validate a computed tomography (CT)-based radiomics nomogram for the pre-treatment prediction of TACE refractoriness.


This retrospective study consisted of a training dataset (n = 137) and an external validation dataset (n = 81) of patients with clinically/pathologically confirmed HCC who underwent repeated TACE from March 2009 to March 2016. Radiomics features were retrospectively extracted from preoperative CT images of the arterial phase. The pre-treatment radiomics signature was generated using least absolute shrinkage and selection operator Cox regression analysis. A CT-based radiomics nomogram incorporating clinical risk factors and the radiomics signature was built and verified by calibration curve and decision curve analyses. The usefulness of the CT-based radiomics nomogram was assessed by Kaplan-Meier curve analysis. We used the concordance index to conduct head-to-head comparisons of the radiomics nomogram with the other four models (Assessment for Retreatment with Transarterial Chemoembolization score; α-fetoprotein, Barcelona Clinic Liver Cancer, Child-Pugh, and Response score; CT-based radiomics signature; and clinical model). All analyses were conducted according to the transparent reporting of a multivariable prediction model for individual prognosis or diagnosis statement.


The median duration of follow-up was 61.3 mo (interquartile range, 25.5-69.3 mo) for the training cohort and 67.1 mo (interquartile range, 32.4-71.3 mo) for the validation cohort. The median number of TACE sessions was 4 (range, 3-7) in both cohorts. Eight radiomics features were chosen from 869 candidate features to build a radiomics signature. The CT-based radiomics nomogram included the radiomics score (hazard ratio = 3.9, 95% confidence interval: 3.1-8.8, P < 0.001) and four clinical factors and classified patients into high-risk (score > 3.5) and low-risk (score ≤ 3.5) groups with markedly different prognoses (overall survival: 12.3 mo vs 23.6 mo, P < 0.001). The accuracy of the nomogram was considerably higher than that of the other four models. The calibration curve and decision curve analyses verified the usefulness of the CT-based radiomics nomogram for clinical practice.


The newly constructed CT-based radiomics nomogram can be used for the pre-treatment prediction of TACE refractoriness, which may provide better guidance for decision making regarding further TACE treatment.

Keywords: Hepatocellular carcinoma, Transarterial chemoembolization, Refractoriness, Radiomics, Nomogram, Computed tomography

Core Tip: At present, it is still difficult to predict transarterial chemoembolization (TACE) refractoriness. The main finding of this study is that our computed tomography (CT)-based radiomics nomogram can be used to individually predict patients’ refractory state before the first session of TACE. The predictive calibration curves of the training and validation datasets demonstrated agreement with the ideal curve. This CT-based radiomics nomogram may provide an unprecedented opportunity to improve clinical decision making for the patients who are repeatedly treated by TACE and, eventually, improve the overall survival of these patients.