Published online Feb 14, 2020. doi: 10.3748/wjg.v26.i6.657
Peer-review started: November 19, 2019
First decision: December 7, 2019
Revised: January 8, 2020
Accepted: January 15, 2020
Article in press: January 15, 2020
Published online: February 14, 2020
Transarterial chemoembolization (TACE) is the most commonly used treatment in patients with unresectable hepatocellular carcinoma (HCC). However, the treatment outcome for such patients varies greatly. Apart from the differences in TACE techniques, the heterogeneity of liver dysfunction, tumor burden and other relevant factors should be carefully considered.
Previously, several prognostic systems have been proposed for risk stratification and clinical decision-making in first TACE and repeated TACE (re-TACE). Nevertheless, it is unknown which model has the highest predictive ability and should be chosen in clinical practice.
In this nationwide multicenter study, we aimed to validate the existing prognostic models for TACE treatment, compare their predictive abilities for overall survival, and finally identify the optimal scoring systems for first TACE and re-TACE in HCC patients.
The prognostic values of the Hepatoma Arterial-embolization Prognostic (HAP) scoring system and its modified versions (mHAP, mHAP2 and mHAP3), as well as the six-and-twelve criteria were compared in 1107 unresectable HCC patients treated with at least one session of TACE, while the same analyses were conducted in 912 patients receiving re-TACE to evaluate the ART (assessment for re-treatment with TACE) and ABCR (alpha-fetoprotein, Barcelona Clinic Liver Cancer, Child-Pugh and Response) systems for post re-TACE survival (PRTS).
With regard to the initial TACE treatment, six-and-twelve criteria had the highest correlation and consistency with radiological response and the mHAP3 criteria had the optimal discrimination value for overall survival. For re-TACE therapy, the ABCR score significantly identified patients with improved PRTS, while the ART system failed to do so. Finally, combining mHAP3 and ABCR systems could discriminate candidates suitable for TACE with improved outcomes compared with non-candidates.
The results from this study suggest that there is high heterogeneity in patients with unresectable HCC and receiving TACE treatment. The six-and-twelve criteria were closely correlated with radiological response, mHAP3 and ABCR were reliable prognostic systems for first TACE and re-TACE. The sequential combination of these systems would facilitate risk stratification and outcome prediction.
This study clearly highlights the need for risk stratification of unresectable HCC patients treated with TACE. Comparing the prognostic abilities among the existing scoring systems, we recommend the combined use of mHAP3 and ABCR for survival prediction of HCC patients receiving TACE for the first time, which would not only refine the prognostic stratification but also facilitate individual management. Therefore, future studies focusing on external validations in a large population are necessary.