Tumor protrusion assessment and clinical integration for enhanced mortality risk prediction in spontaneously ruptured hepatocellular carcinoma

Table 1 Baseline characteristics of the study participants (n = 89)

Variables	n (%)/median (IQR)
Age (years)	59.0 (51.7-66.1)
Sex (men/women)	73 (82)/16 (18)
Hepatitis B virus (positive/negative)	40 (45)/49 (55)
Hepatitis C virus (positive/negative)	18 (20)/71 (80)
Shock on admission (yes/no)	36 (40)/53 (60)
Time from imaging diagnosis to TAE/TACE (hours)	12.1 (5.2-72.0)
Biochemical parameters
Hemoglobin (g/dL)	9.9 (8.1-11.5)
Platelet count (× 103/μL)	167 (119-253)
Albumin (g/dL)	3.2 (2.8-3.5)
Total bilirubin (mg/dL)	1.22 (0.77-2.04)
AST (U/L)	102 (58-181)
ALT (U/L)	55 (33-100)
ALP (U/L)	122 (76-196)
INR	1.27 (1.16-1.44)
Creatinine (mg/dL)	0.95 (0.72-1.22)
Alpha-fetoprotein (ng/mL)	226 (22-14327)
Alpha-fetoprotein (< 200/≥ 200 ng/mL)	41 (46)/48 (54)
Imaging parameters
Tumor number (single/multiple)	27 (30)/62 (70)
Ruptured tumor size (cm)	7.8 (5.9-11.1)
Ruptured tumor location (caudate/left/right)	1 (1)/20 (23)/68 (76)
Portal vein thrombosis (present/absent)	33 (37)/56 (63)
Extrahepatic metastasis (present/absent)	13 (15)/76 (85)
Child-Pugh class (A/B/C)	47 (53)/39 (44)/3 (3)
BCLC stage (A/B/C)	8 (9)/46 (52)/35 (39)
Embolic agents
Gelatin sponge	72 (81)
Gelatin sponge + polyvinyl alcohol	2 (2)
Lipiodol and gelatin sponge	15 (17)
Protrusion assessment
Protrusion area	15.4 (7.5-31.4)
Protrusion diameter	3.0 (1.7-4.7)
Protrusion percentage	40% (26%-58%)
Clinical outcome
30-day mortality	22 (25)
Overall mortality	83 (93)
Overall survival	5.03 (3.12-6.24)

IQR: Interquartile range; TAE: Transarterial embolization; TACE: Transarterial chemoembolization; AST: Aspartate aminotransferase; ALT: Alanine aminotransferase; ALP: Alkaline phosphatase; INR: International normalized ratio; BCLC: Barcelona Clinic Liver Cancer.

Table 2 Univariate and multivariable logistic regression analysis for predictors of 30-day mortality

Variable	Reference	Univariate analysis		Multivariate analysis
		Odds ratio (95%CI)	P value	Adjusted odds ratio (95%CI)	P value
Age ≥ 65 years	< 65 years	0.56 (0.15-1.74)	0.348
Sex (men)	Women	1.52 (0.43-7.17)	0.543
Hepatitis B positive	Negative	0.62 (0.22-1.66)	0.353
Hepatitis C positive	Negative	3.26 (1.07-9.86)	0.035
Presence of shock	Absence	1.79 (0.67-4.80)	0.240
Hemoglobin ≤ 10 g/dL	> 10 g/dL	2.75 (1.00-8.45)	0.060
Platelet count ≤ 100000/μL	> 100000/μL	0.51 (0.07-2.11)	0.406
Albumin ≤ 3.0 g/dL	> 3.0 g/dL	5.10 (1.83-15.88)	0.003	4.21 (1.39-14.12)	0.014
Total bilirubin ≥ 2.5 mg/dL	< 2.5 mg/dL	4.21 (1.34-13.48)	0.013	5.48 (1.43-24.24)	0.016
AST ≥ 100 U/L	< 100 U/L	6.67 (2.21-25.06)	0.002
ALT ≥ 100 U/L	< 100 U/L	2.16 (0.74-6.16)	0.150
ALP ≥ 150 U/L	< 150 U/L	3.83 (1.42-10.96)	0.009
INR ≥ 1.2	< 1.2	2.44 (0.85-8.13)	0.115
Creatinine ≥ 1.5 mg/dL	< 1.5 mg/dL	1.50 (0.42-4.76)	0.506
Alpha-fetoprotein ≥ 200 ng/mL	< 200 ng/mL	1.70 (0.64-4.75)	0.295
Multiple tumor nodules	Single	3.53 (1.07-16.14)	0.060
Tumor size ≥ 5 cm	< 5 cm	5.06 (0.92-94.67)	0.130
Portal vein thrombosis: Present	Absent	2.63 (0.99-7.19)	0.055
Child-Pugh class B and C	Class A	1.89 (0.72-5.17)	0.201
BCLC stage C	Stage A and B	3.16 (1.18-8.81)	0.023
Procedure type: TAE	TACE	5.55 (1.01-103.65)	0.108
Protrusion area ≥ 8.7 cm2	< 8.7 cm2	6.34 (1.66-41.81)	0.018	7.34 (1.66-55.26)	0.020
Protrusion diameter ≥ 1.6 cm	< 1.6 cm	7.71 (1.44-143.24)	0.054
Protrusion percentage ≥ 50%	< 50%	0.84 (0.29-2.28)	0.733

CI: Confidence interval; AST: Aspartate aminotransferase; ALT: Alanine aminotransferase; ALP: Alkaline phosphatase; INR: International normalized ratio; BCLC: Barcelona Clinic Liver Cancer; TAE: Transarterial embolization; TACE: Transarterial chemoembolization.

Table 3 β coefficient and corresponding rounded risk score from results of the multivariable logistic regression analysis (n = 89)

Prognostic factors	β coefficient	Adjusted odds ratio (95%CI)	P value	Weighted risk score
Protrusion area ≥ 8.7 cm2	1.9937	7.34 (1.66-55.26)	0.020	6
Total bilirubin ≥ 2.5 mg/dL	1.7020	5.48 (1.43-24.24)	0.016	5
Albumin ≤ 3.0 g/dL	1.4367	4.21 (1.39-14.12)	0.014	4

CI: Confidence interval.

Table 4 Summary of the 30-day mortality rates of different risk groups stratified according to the protrusion area-bilirubin-albumin score

Risk group	Score	n (%)	30-day mortality (95%CI)	Median survival (months)
Low	≤ 8	58 (65)	8.6% (3.2%-18.1%)	6.18 (5.03-9.53)
Intermediate	9-10	20 (23)	40.0% (19.1%-63.9%)	2.12 (0.39-7.52)
High	≥ 11	11 (12)	81.8% (48.2%-97.7%)	0.33 (0.16-NA)

CI: Confidence interval; NA: Not available.