Validation of the ALBI-TAE model and comparison of seven scoring systems for predicting survival outcome in patients with intermediate‐stage hepatocellular carcinoma undergoing chemoembolization

Baseline characteristics

The study included 480 patients who met the full set of inclusion and exclusion criteria. Their baseline patient characteristics are displayed in Table 2. The mean age was 62 years, and 72% were men. The main etiology of HCC was hepatitis B virus (54%) followed by hepatitis C virus (21%), and alcohol (17%). The Child–Pugh classes were A (66%) and B (34%). At the initial diagnosis of HCC, the most common largest tumor size was > 5 cm (60%) followed by 3–5 cm (26%). Tumor sizes ranged 1.0–21.7 cm and the mean tumor size ± SD was 7.2 ± 4.6 cm. More than half (55%) of the patients had 2–5 tumor nodules. Median values for serum alanine transaminase and platelet count were 40 (27–61) U/L and 122 × 103/mm3 (76–201), respectively. Most patients had serum AFP ≤ 200 ng/mL (63%). The median (IQR) serum albumin and total bilirubin levels were 3.4 (3.0,3.8) g/dL and 0.83 (0.54,1.39) mg/dL, respectively. Tumor response rates by mRECIST with complete response, partial response, stable disease, and progressive disease were 15% (74 patients), 41% (195 patients), 25% (118 patients), and 19% (93 patients), respectively. In addition, most patients had ALBI-TAE grade B (45%).

Table 2 Baseline patient demographic and clinical characteristics of 480 patients with intermediate-stage HCC who underwent TACEAnalysis of the prognostic factors for overall survival (OS)

In univariate analysis, size of the largest lesion, number of tumors, serum AFP level, serum albumin level, serum total bilirubin level, Child–Pugh class, treatment response to initial TACE, and ALBI-TAE model were associated with poor OS. Multivariate Cox model showed that Child–Pugh class B (hazard ratio [HR] 1.52, 95% CI 1.23–1.87; P < 0.001), treatment response to initial TACE (HR 1.65, 95% CI 1.35–2.01; P < 0.001), and ALBI-TAE model (group B vs. group A [HR 1.59, 95% CI 1.06–2.40: P = 0.026], group C vs. group A [HR 2.54, 95% CI 1.66–3.88; P < 0.001], and group D vs. group A [HR 3.73, 95% CI 2.31–6.01; P < 0.001]) were independently associated with increased mortality in these patients (Table 3).

Table 3 Univariate and multivariate analysis of prognostic factors associated with overall survivalSurvival analysis

The median (IQR) OS of the entire cohort was 16.6 months (14.9,18.4 months). The 1-, 3-, and 5-year OS rates were 60%, 22%, and 11% respectively. By stratifying the ALBI-TAE model (groups A, B, C, and D), the median (IQR) OS rates were 40.80 (29.04,105.19), 20.14 (17.61,23.85), 10.58 (9.17,14.13), and 7.54 (4.37,9.33) months (Fig. 1). The 1-, 3-, and 5-year OS rates were 91%, 51%, and 40%, respectively, for ALBI-TAE A; 72%, 26%, and 12%, respectively, for ALBI-TAE B; 48%, 14%, and 5%, respectively, for ALBI-TAE C; and 27%, 9%, and 4%, respectively, for ALBI-TAE D. There were significant survival differences between the four groups (P < 0.001).

Fig. 1figure 1

Kaplan–Meier curves of overall survival among intermediate-stage HCC patients who underwent TACE stratified by the ALBI-TAE model

Comparing the performances of the ALBI-TAE model and other scores .

Table 4 provides a detailed overview of the head-to-head comparison. Among these seven scores, the ALBI-TAE model had the highest C-index of 0.633, which suggested a better prognostic performance to discriminate survival in TACE patients, followed by the HAP score (0.629), mHAP-II score (0.624), SEC (0.578), SAT score (0.574), Bolondi’s subclassification (0.570), and tumor burden score (0.546). The IBS values for the study interval (0–60 months) were 0.152 for the ALBI-TAE model, 0.153 for the mHAP-II score, and 0.154 for the HAP score. Based on the Kaplan Meier estimates of the unstratified sample, the reference IBS was 0.169. The prediction error curves based on the IBS are shown in Fig. 2.

Table 4 Head-to-head comparison of the performance and discriminative ability of the seven models in predicting survival for intermediate-stage HCC patients who underwent TACEFig. 2figure 2

Predictive error curve and integrated Brier score (IBS) for Kaplan–Meier estimates based on the ALBI-TAE model (blue), mHAP-II score (green), HAP score (red), seven-eleven-criteria (gray), six-and-twelve score (pink), Bolondi’s subclassification (purple), tumor burden score (orange), and compared with the unstratified sample (black)

Treatment response and complications stratified by the ALBI-TAE model

Treatment response and complications after TACE were evaluated based on the ALBI-TAE model (Table 5). Among the 480 patients, 269 responded well to TACE, while 211 had a poor response. Compared to ALBI-TAE group A, the chance of TACE response was significantly lower in ALBI-TAE group C (adjusted OR 0.14, 95% CI 0.06–0.34) and ALBI-TAE group D (adjusted OR 0.04, 95% CI 0.01–0.12). Patients in ALBI-TAE group B had a numerically lower chance of TACE response compared to patients in ALBI-TAE group A, although not statistically significant (adjusted OR 0.44, 95% CI 0.19–1.04). Postembolization syndrome was more common in ALBI-TAE groups B (19%), C (31%), and D (59%) compared to patients in ALBI-TAE group A (11%) with significant differences (P < 0.001). Moreover, ALBI-TAE group A had no incidence of liver decompensation, while groups B, C, and D had rates of 5%, 9%, and 29%, respectively. These differences between the groups were significant (P < 0.001).

Table 5 Treatment response and complications of intermediate-stage HCC patients who underwent TACE, stratified by the ALBI-TAE model

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