The main goal of treatment for advanced HCC is to prolong the survival time of patients [14]. As a local treatment to control tumor progression, TACE plays an important role in clinical practice [12, 15]. Because of the individual differences between patients with HCC, not all patients can benefit from TACE [16]. Many studies have focused on prognostic risk factors after TACE in patients with advanced HCC. Several studies have found that tumor characteristics are important prognostic factors for HCC. Several studies have suggested that the immune and nutritional status of patients is prognostic factors for HCC. Many studies have constructed many nomograms to predict the prognosis of HCC patients based on these risk factors [9,10,11]. However, there is a lack of studies to predict whether patients with advanced HCC will benefit from multiple TACE treatments. This study aimed to develop and validate a model for predicting who can benefit from multiple TACE in HCC patients.

After setting the clinical endpoint of benefiting from multiple TACE, univariate and multivariate logistic regression analyses were performed, and four independent risk factors were screened out in this study, including complete envelope, hepatic lobes, tumor number, and AFP. The integrity of the HCC envelope reflects the invasiveness of the tumor, which will affect the sensitivity of the tumor to receive treatment, thus affecting the prognosis of patients. Therefore, the integrity of the envelope is an important prognostic factor in patients with HCC receiving TACE treatment [17]. The extent of HCC invasion in the hepatic lobes reflects the degree of tumor differentiation, and the larger the extent of invasion, the worse the degree of tumor differentiation may be. Poor differentiation may lead to poor prognosis [18, 19]. Tumor number and AFP level represent the level of tumor burden. A large number of tumors and a high AFP level reflect a high tumor burden, which may not only affect the nutritional status of patients, but also further affect the acceptance of HCC patients in TACE treatment [20,21,22]. All these risk factors may lead to poor prognosis. Based on these factors, a nomogram was constructed to predict patients who would benefit from multiple TACE. This study also used the K-M curves to compare the overall survival between the benefit group and the no-benefit group in the development set and the validation set, and the differences were statistically significant. This indicates that benefiting from multiple TACE can affect the prognosis of HCC patients.

The nomogram constructed in the development set showed good predictive ability in both the development set and the validation set. Satisfactory AUCs were obtained in both the development and validation sets, which indicated that the prediction ability of the model was good. The calibration curves and clinical decision curves in the development set and validation set showed that the nomogram constructed in this study could achieve high prediction accuracy and get good clinical benefits. Through this model, HCC patients who are suitable for multiple TACE treatments can be found clinically, while for HCC patients who are not suitable, clinicians can add some necessary systemic therapies, such as [23, 24].

The nomogram constructed in this study also has the following strengths. The variables required in this study were tumor characteristics that were readily available in clinical practice. Compared with genetic testing, which is an expensive indicator, this model has high economic practicability. It is suitable for application in all levels of cancer treatment centers. More importantly, there are no studies addressing what kind of HCC patients would benefit from multiple TACE. This study achieved this goal.

However, this study has some limitations. First of all, this study is a single-center study, and its conclusions still need to be supported by multi-center and large sample size data. Secondly, this study is retrospective, and the constructed nomogram still needs to be further tested by prospective studies. Moreover, the nomogram constructed in this study is suitable for predicting whether HCC patients can benefit from multiple TACE treatments, and its role in predicting the benefit of other treatments or predicting the prognosis of HCC patients is not clear at present, which needs further research to confirm.