Validation of the six-and-twelve criteria among patients with hepatocellular carcinoma and performance score 1 receiving transarterial chemoembolization

Sultan's Score: A Novel Predictive Score to Predict Complete Response Following Drug-Eluting Bead Chemoembolization

BACKGROUND

Transcatheter arterial chemoembolization (TACE) is a well-known standard treatment for hepatocellular carcinoma (HCC); however, the effectiveness of this treatment can vary among patients.

OBJECTIVES

This study aimed to develop a novel imaging-based prediction score (Sultan's score) to predict complete response after treatment.

METHODS

From January 2015 to 2021, 41 patients with solitary HCC, admitted at King Saud University Medical City, Riyadh, Saudi Arabia, were treated with drug-eluting TACE (DEBTACE). Clinical data, tumor details, treatment specifics, and outcomes were gathered retrospectively. Sultan's score incorporates five imaging-based elements, namely, well-defined tumor borders, presence of tumor capsule, tumor size, arterial hyper enhancement, and hypertrophic arterial feeder. The cut-off value of Sultan's score was determined by calculating the maximum Youden index using the receiver operating characteristic curve to accurately predict complete treatment response to DEBTACE.

RESULTS

Following two DEBTACE sessions, 28 (68.3%) and 13 (31.7%) patients showed complete and partial responses, respectively. The mean ± standard deviation and median (interquartile range) of the Sultan's score in patients with a complete treatment response were 3.93 ± 0.72 and 4 (4-4), and the corresponding values in patients with a partial response were 2.77 (0.93) and 3 (2-3.5), respectively. A cut-off value of 3.5 for the Sultan's score had a sensitivity and specificity of 78.6% and 76.9%, respectively, in predicting a complete treatment response. The area under the curve was 0.827 (95% confidence interval: 0.688-0.966).

CONCLUSIONS

We developed a novel imaging-based scoring system (Sultan's score) for predicting complete response in patients with HCC following DEBTACE.

Contrast-Enhanced CT Imaging Features Combined with Clinical Factors to Predict the Efficacy and Prognosis for Transarterial Chemoembolization of Hepatocellular Carcinoma

RATIONALE AND OBJECTIVES

Accurate prediction of treatment response to transarterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC) is critical for precision treatment. This study aimed to develop a comprehensive model (DLRC) that incorporates contrast-enhanced computed tomography (CECT) images and clinical factors to predict the response to TACE in patients with HCC.

MATERIALS AND METHODS

A total of 399 patients with intermediate-stage HCC were included in this retrospective study. Deep learning and radiomic signatures were established based on arterial phase CECT images, Correlation analysis and the least absolute shrinkage and selection (LASSO) regression analysis were applied for features selection. The DLRC model incorporating deep learning radiomic signatures and clinical factors was developed using multivariate logistic regression. The area under the receiver operating characteristic curve (AUC), calibration curve and decision curve analysis (DCA) were used to evaluate the performance of the models. Kaplan-Meier survival curves based on the DLRC were plotted to assess overall survival in the follow-up cohort (n = 261).

RESULTS

The DLRC model was developed using 19 quantitative radiomic features, 10 deep learning features, and 3 clinical factors. The AUC of the DLRC model was 0.937 (95% confidence interval [CI], 0.912-0.962) and 0.909 (95% CI, 0.850-0.968) in the training and validation cohorts, respectively, outperforming models established with two signatures or a single signature (p < 0.05). Stratified analysis showed that the DLRC was not statistically different between subgroups (p > 0.05), and the DCA confirmed the greater net clinical benefit. In addition, multivariable cox regression revealed that DLRC model outputs were independent risk factors for the overall survival (hazard ratios: 1.20, 95% CI: 1.03-1.40; p = 0.019).

CONCLUSION

The DLRC model exhibited a remarkable accuracy in predicting response to TACE, and it can be utilized as a potent tool for precision treatment.

Transarterial chemoembolization for advanced hepatocellular carcinoma without macrovascular invasion or extrahepatic metastasis: analysis of factors prognostic of clinical outcomes

Objectives

To evaluate the safety and efficacy of TACE and factors predicting survival in patients with advanced hepatocellular carcinoma (HCC) without macrovascular invasion (MVI) or extrahepatic spread (EHS).

Methods

This single-center retrospective study included 236 treatment-naïve patients who underwent TACE as first-line treatment for advanced HCC without MVI or EHS between January 2007 and December 2021.

Results

Following TACE, the median overall survival (OS) was 24 months. Multivariate Cox regression analyses revealed that tumor number ≥4 (risk point: 3), maximal tumor size >10 cm (risk point: 2), Child-Pugh class B (risk point: 2), alpha-fetoprotein (AFP) concentration ≥400 ng/mL (risk point: 2), and presence of HCC rupture (risk point: 2) were risk factors significantly associated with OS. The expected median OS among patients with <2, 2-4, and 5-9 risk points were 72, 29, and 12 months respectively. The major complication rates were significantly lower in patients with maximal tumor size ≤10 cm than in those with maximal tumor size >10 cm (4% [5/138] vs 21% [21/98], p = 0.001).

Conclusion

TACE may be safe and effective in selected patients with advanced HCC without MVI or EHS, with a median OS of 24 months. Patients with limited tumor burden, compensated liver function, absence of HCC rupture, and favorable biologic markers may benefit the most from TACE. TACE is not recommended for patients with huge HCCs (>10 cm) because of its high rate of major complications (21%).

Validation of the "Six-and-Twelve" Prognostic Score in Transarterial Chemoembolization-Treated Hepatocellular Carcinoma Patients

INTRODUCTION

The "six-and-twelve" prognostic score was proposed recently to predict survival rate in patients with unresectable hepatocellular carcinoma (HCC) treated with transarterial chemoembolization (TACE). However, it has not been validated externally. We validated this score and previous prognostic scores in Thai HCC patients treated with TACE.

METHODS

We identified all HCC patients who underwent TACE between January 2007 and December 2018 at our hospital. The inclusion criteria were treatment-naive, unresectable HCC BCLC-A and BCLC-B; if cirrhosis was present, Child-Pugh score ≤7; and baseline performance status 0-1.

RESULTS

Of 716 HCC patients undergoing TACE, 281 (mean age, 61.1 years; 73.0% men, 92.2% with cirrhosis) were eligible. Approximately half of the patients had hepatitis B virus. Median overall survival was 20.3 (95% confidence interval, 16.4-26.3) months. By stratifying with the "six-and-twelve" score (≤6, >6-12, >12), median (95% confidence interval) overall survival was 35.1 (26.4-53.0), 16.0 (11.6-22.6), and 7.6 (5.4-14.9) months, respectively. Area under the receiver operating characteristic curves (AUROCs) predicting death at 1, 2, and 3 years for the "six-and-twelve" score were 0.714, 0.700, and 0.688, respectively. Compared with the other currently available scores, the AUROC predicting death at 1 year for the "six-and-twelve" score was the most predictive and better than other models except the up-to-seven model.

DISCUSSION

Our study confirms the value of the "six-and-twelve" score to predict survival rate of unresectable HCC treated with TACE. However, in our validation cohort, AUROC of the "six-and-twelve" score was slightly lower than that of the original Chinese cohort (0.73).

Immune infiltration-associated serum amyloid A1 predicts favorable prognosis for hepatocellular carcinoma

BACKGROUND

Serum amyloid A1 (SAA1) is an acute-phase protein involved in acute or chronic hepatitis. Its function is still controversial. In addition, the effect of the expression of SAA1 and its molecular function on the progression in hepatocellular carcinoma (HCC) is still unclear.

AIM

To demonstrate the expression of SAA1 and its effect on the prognosis in HCC and explain further the correlation of SAA1 and immunity pathways.

METHODS

SAA1 expression in HCC was conducted with The Cancer Genome Atlas-Liver Hepatocellular Carcinoma (TCGA-LIHC) in GEPIA tool, and the survival analysis based on the SAA1 expression level was achieved in the Kaplan-Meier portal. The high or low expression group was then drawn based on the median level of SAA1 expression. The correlation of SAA1 and the clinical features were conducted in the UALCAN web-based portal with TCGA-LIHC, including tumor grade, patient disease stage, and the TP53 mutation. The correlation analysis between SAA1 expression and TP53 mutation was subjected to the TCGA portal. The tumor purity score and the immune score were analyzed with CIBERSORT. The correlation of SAA1 expression and tumor-infiltrating lymphocytes was achieved in TISIDB web-based integrated repository portal for tumor-immune system interactions. GSE125336 dataset was used to test the SAA1 expression in the responsive or resistant group with anti-PD1 therapy. Gene set enrichment analysis was applied to evaluate the gene enrichment signaling pathway in HCC. The similar genes of SAA1 in HCC were identified in GEPIA, and the protein-protein interaction of SAA1 was conducted in the Metascape tool. The expression of C-X-C motif chemokine ligand 2, C-C motif chemokine ligand 23, and complement C5a receptor 1 was studied and overall survival analysis in HCC was conducted in GEPIA and Kaplan-Meier portal, respectively.

RESULTS

SAA1 expression was decreased in HCC, and lower SAA1 expression predicted poorer overall survival, progression-free survival, and disease-specific survival. Furthermore, SAA1 expression was further decreased with increased tumor grade and patient disease stage. Also, SAA1 expression was further downregulated in patients with TP53 mutation compared with patients with wild type TP53. SAA1 expression was negatively correlated with the TP53 mutation. Lower SAA1 predicted poorer survival rate, especially in the patients with no hepatitis virus infection, other than those with hepatitis virus infection. Moreover, the SAA1 expression was negatively correlated with tumor purity. In contrast, SAA1 expression was positively correlated with the immune score in HCC, and the correlation analysis between SAA1 expression and tumor-infiltrating lymphocytes also showed a positive correlation in HCC. Decreased SAA1 was closely associated with the immune tolerance of HCC. C-X-C motif chemokine ligand 2 and C-C motif chemokine ligand 23 genes were identified as the hub genes associated with SAA1, which could also serve as favorable prognosis markers for HCC.

CONCLUSION

SAA1 is downregulated in the liver tumor, and it is closely involved in the progression of HCC. Lower SAA1 expression indicates lower survival rate, especially for those patients without hepatitis virus infection. Lower SAA1 expression also suggests lower immune infiltrating cells, especially for those with immune cells exerting anti-tumor immune function. SAA1 expression is closely associated with the anti-tumor immune pathways.