Retrospective Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Apr 21, 2020; 26(15): 1805-1819
Published online Apr 21, 2020. doi: 10.3748/wjg.v26.i15.1805
Validation of the six-and-twelve criteria among patients with hepatocellular carcinoma and performance score 1 receiving transarterial chemoembolization
Zhe-Xuan Wang, Jing Li, En-Xin Wang, Dong-Dong Xia, Wei Bai, Qiu-He Wang, Jie Yuan, Xiao-Mei Li, Jing Niu, Zhan-Xin Yin, Jie-Lai Xia, Dai-Ming Fan, Guo-Hong Han
Zhe-Xuan Wang, Jing Li, En-Xin Wang, Dong-Dong Xia, Wei Bai, Qiu-He Wang, Jie Yuan, Xiao-Mei Li, Jing Niu, Zhan-Xin Yin, Dai-Ming Fan, Guo-Hong Han, Department of Liver Disease and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an 710032, Shaanxi Province, China
Jie-Lai Xia, Department of Health Statistics, Fourth Military Medical University, Xi’an 710032, Shaanxi Province, China
Author contributions: Wang ZX, Li J and Wang EX contributed equally to this work; Wang ZX, Wang EX and Han GH designed research; Wang ZX, Wang EX, Xia DD and Bai W performed research and collected data; Wang ZX, Li J and Wang EX analyzed data; Xia DD and Xia JL contributed to statistical support; Wang ZX, Li J, Xia DD, Bai W, Wang EX, Wang QH, Yuan J, Li XM, Niu J, Yin ZX, Xia JL, Fan DM and Han GH contributed to administrative, technical or material support; Wang ZX, Li J, Wang EX and Han GH wrote the paper.
Institutional review board statement: The study protocol was reviewed and approved by the institutional Ethics Committees of the First Affiliated Hospital of the Fourth Military Medical University.
Informed consent statement: Patients were not required to give informed consent for this study because the analysis used anonymous clinical data that were obtained after each patient agreed to treatment by written consent.
Conflict-of-interest statement: The authors have no conflict of interest to disclose.
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: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Guo-Hong Han, MD, PhD, Professor, Department of Liver Disease and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, 15 West Changle Road, Xi’an 710032, Shaanxi Province, China. hangh@fmmu.edu.cn
Received: December 12, 2019
Peer-review started: December 12, 2019
First decision: January 7, 2020
Revised: March 13, 2020
Accepted: March 27, 2020
Article in press: March 27, 2020
Published online: April 21, 2020
ARTICLE HIGHLIGHTS
Research background

According to the international guidelines, the advanced stage of hepatocellular carcinoma (HCC) covers patients with liver-confined HCC and Eastern Cooperative Oncology Group (ECOG) performance status score 1. Despite the recommended standard treatment of systemic therapy, these patients are frequently treated with transarterial chemoembolization (TACE) in real world clinical practice.

Research motivation

Previously, some studies demonstrated different prognoses between advanced HCC patients with ECOG 1 alone and others with macrovascular invasion or extrahepatic spread. Whether such patients should be classified into intermediate stage and treated with TACE still remains unknown. Specific studies focusing on the survival is necessary.

Research objectives

This nationwide multicenter study aimed to investigate treatment outcomes of TACE in advanced HCC patients with ECOG 1 alone and propose a specific prognostic model.

Research methods

Several potential prognostic models were developed based on univariate analyses and multivariate Cox regression analyses. Then, the discriminatory ability of them were compared with six-and-twelve (6&12) criteria, defined as the algebraic sum of tumor size (cm) and tumor number, in 792 patients and their subgroups. Contour plot of 3-year survival probability and nomogram were used to illustrate the individual survival prediction of 6&12 criteria in advanced HCC patients with ECOG 1 alone receiving TACE.

Research results

The analyses showed that tumor size, tumor number, α-fetoprotein level, albumin–bilirubin grade and total bilirubin were prognostic factors of overall survival (OS). In the comparisons between 6&12 criteria and three newly proposed models containing different prognostic factors, the 6&12 criteria retained the highest predictive ability and was the easiest to use. Additionally, the 6&12 criteria was correlated with OS in various subgroups of patients and could stratify patients into three risk strata with cut-off values “6” and “12”.

Research conclusions

The results from this study suggest that TACE is effective for advanced HCC patients with ECOG 1 alone. The 6&12 criteria including two robust prognostic factors (tumor size and tumor number) of OS could be applied in risk stratification and individual prediction, which might help with clinical decision-making.

Research perspectives

This study explored the applicability of TACE for advanced HCC patients with ECOG 1 alone and proposed a predictive score for OS. Also, other possible treatment approaches used in clinical practice exist. Future studies should investigate the outcomes of different treatments and compare them with TACE to further manage these patients with the most appropriate therapy.