Retrospective Cohort Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Mar 14, 2020; 26(10): 1042-1055
Published online Mar 14, 2020. doi: 10.3748/wjg.v26.i10.1042
Prognostic factors and predictors of postoperative adjuvant transcatheter arterial chemoembolization benefit in patients with resected hepatocellular carcinoma
Ming-Yu Chen, Sarun Juengpanich, Jia-Hao Hu, Win Topatana, Jia-Sheng Cao, Chen-Hao Tong, Jian Lin, Xiu-Jun Cai
Ming-Yu Chen, Jia-Sheng Cao, Xiu-Jun Cai, Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310000, Zhejiang Province, China
Ming-Yu Chen, Sarun Juengpanich, Jia-Hao Hu, Win Topatana, Xiu-Jun Cai, School of Medicine, Zhejiang University, Hangzhou 310016, Zhejiang Province, China
Ming-Yu Chen, Engineering Research Center of Cognitive Healthcare of Zhejiang Province, Hangzhou 310000, Zhejiang Province, China
Chen-Hao Tong, Department of General Surgery, Shaoxing People’s Hospital, Zhejiang University, Shaoxing 312000, Zhejiang Province, China
Jian Lin, Department of General Surgery, Longyou People’s Hospital, Quzhou 314400, Zhejiang Province, China
Author contributions: Chen MY, Cao JS, Juengpanich S, and Hu JH were involved in study design, collected and analyzed data, and drafted the paper; Topatana W, Tong CH, and Lin J collected and checked data; Cai XJ designed and supervised the study; and all authors wrote the paper.
Supported by Opening Fund of Engineering Research Center of Cognitive Healthcare of Zhejiang Province, No. 2018KFJJ09; and National Natural Science Foundation of China, No. 81827804.
Institutional review board statement: The study was reviewed and approved by the Sir Run-Run Shaw Hospital Institutional Review Board.
Informed consent statement: Patients were not required to give informed consent to the study because the analysis used anonymous clinical data that were obtained after each patient agreed to treatment by written consent.
Conflict-of-interest statement: All authors declare no conflicts of interest related to this article.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
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: Xiu-Jun Cai, FACS, FRCS, MD, PhD, Professor, Surgeon, Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, No. 3, East Qingchun Road, Hangzhou 310000, Zhejiang Province, China. srrsh_cxj@zju.edu.cn
Received: November 13, 2019
Peer-review started: November 13, 2019
First decision: December 4, 2019
Revised: December 20, 2019
Accepted: February 9, 2020
Article in press: February 9, 2020
Published online: March 14, 2020
ARTICLE HIGHLIGHTS
Research background

Transcatheter arterial chemoembolization (TACE) is one of the primary treatment options for hepatocellular carcinoma (HCC) patients with intermediate and advanced stages, and is widely recommended in preoperative and postoperative therapy, due to satisfactory results in eliminating tiny invisible tumor spots with few complications. Recent studies have demonstrated that postoperative adjuvant TACE (PA-TACE) can improve the outcome of HCC associated with hepatic vein invasion and prolong overall survival (OS) in patients with multinodular HCC. However, it is still unclear whether PA-TACE can prolong OS in patients with HCC after R0 hepatectomy.

Research motivation

Although analyses of potential predictive factors for PA-TACE benefit have been carried out using data from an observational study on HCC patients with microscopic vascular invasion (MVI), the number of patients and the lack of variables prevented accurate differentiation between prognostic and predictive factors. Therefore, we aimed to compare OS following PA-TACE and surgery alone, and to assess prognostic factors for OS and predictive factors of PA-TACE benefit in patients with HCC after R0 hepatectomy.

Research objectives

The main objective of this study was to identify the prognostic and predictive factors that can assist clinicians in selecting HCC patients who would achieve a better OS with PA-TACE. We conducted a retrospective, multi-center study to assess the prognostic factors for HCC and the predictive factors of PA-TACE. The potential prognostic factors identified in this study could lead to the utilization of artificial intelligence to assess the clinical outcome of HCC patients.

Research methods

A total of 653 patients were selected from three centers as original data, and 378 patients (PA-TACE vs surgery alone, 189:189) were identified for exploratory analysis after a propensity-score 1:1 matching analysis. Univariate and multivariate analyses were performed to identify the potential prognostic factors for OS. In order to assess the predictive factors of PA-TACE benefit, the interaction variables between treatments for each subgroup were evaluated using the Cox proportional hazards regression model.

Research results

Compared to the group receiving surgery alone, PA-TACE prolonged the OS rate in patients with resected HCC (P < 0.001). The Barcelona Clinic Liver Cancer system and ferritin-to-hemoglobin ratio (FHR) were used as the prognostic factors for OS in both groups. PA-TACE showed longer OS than surgery alone across subgroups [all hazard ratios (PA-TACE-to-surgery alone) < 1]. Notably, the significantly prolonged OS following PA-TACE was observed in patients with high FHR (P = 0.038) and without MVI (P = 0.048).

Research conclusions

Previous studies have demonstrated improved outcomes following PA-TACE, but it is still unclear whether the combination of PA-TACE and surgery improves the prognosis of patients with resectable HCC. This study demonstrated that FHR and Barcelona Clinic Liver Cancer stages were the most important prognostic factors for OS. Moreover, high FHR [> median (23)] and absence of MVI were predictive factors of PA-TACE benefit, and can be used to assist clinicians in selecting which patients would achieve a better OS with PA-TACE. This study has provided many paths for future research. Tumors evolve spontaneously, and a reliable way of predicting OS and response to PA-TACE is essential for physicians to create a treatment plan that will improve the patient’s prognosis. By using the potential prognostic factors identified in this study, artificial intelligence could be used to assess the clinical outcome of patients with HCC. However, due to the limitations in our study, a prospective study is needed in the future to confirm PA-TACE treatment efficacy and its impact on OS.

Research perspectives

Due to the limitations in this study, several lessons can be learned. Although a propensity score matching analysis was performed, potential bias could not be completely eliminated. Moreover, several clinical variables in the data could not be measured. Hence, a prospective study is needed to confirm PA-TACE treatment efficacy and its impact on OS. This study has provided many paths for future research. Tumors evolve spontaneously, and a reliable way of predicting OS and response to PA-TACE is essential for physicians to create a treatment plan that will improve the patient’s prognosis. By using the potential prognostic factors identified in this study, artificial intelligence could be used to assess the clinical outcome of patients with HCC.