Redefining Tumor Burden in Patients with Intermediate-Stage Hepatocellular Carcinoma: The Seven-Eleven Criteria

Abstract

<b><i>Background and Aims:</i></b> For patients with intermediate-stage hepatocellular carcinoma (HCC), the definition of high tumor burden remains controversial. This study aimed to compare the prognostic value of different criteria of tumor burden in patients with intermediate-stage HCC undergoing transarterial chemoembolization (TACE). <b><i>Methods:</i></b> From 2007 to 2019, 632 treatment-naive patients with intermediate-stage HCC undergoing TACE were retrospectively enrolled. We compared different criteria of tumor burden in discriminating radiologic response and survival, including up-to-7, up-to-11, 5–7, 7 lesions criteria, and newly proposed 7–11 criteria. <b><i>Results:</i></b> The proportions of patients classified as high tumor burden were varied by different criteria. Among the 5 criteria, 7–11 criteria have the best performance to discriminate complete response (CR) and overall survival (OS) after TACE. In patients with low, intermediate, and high tumor burden classified by 7–11 criteria, the CR rate was 21, 12, and 2.5%, respectively (<i>p</i> < 0.001), and the median OS was 33.1, 22.3, and 11.9 months, respectively (<i>p</i> < 0.001). By multivariate analysis, 7–11 criteria were significantly associated with CR (intermediate vs. high burden, odds ratio = 4.617, <i>p</i> = 0.002; low vs. high burden, odds ratio = 8.675, <i>p</i> < 0.001) and OS (intermediate vs. high burden, hazard ratio = 0.650, <i>p</i> < 0.001; low vs. high burden, hazard ratio = 0.520, <i>p</i> < 0.001). Seven to 11 criteria also had the lowest corrected Akaike information criteria, highest homogeneity value, and highest area under the receiver operating characteristic curve in predicting 1-, 2-, and 3-year mortality among all criteria. <b><i>Conclusion:</i></b> Conventional definitions of tumor burden were not optimal for patients with intermediate HCC. The new 7–11 criteria had the best discriminative power in predicting radiologic response and survival in patients with intermediate-stage HCC undergoing TACE.

Tumor Burden in Patients With Hepatocellular Carcinoma Undergoing Transarterial Chemoembolization: Head-to-Head Comparison of Current Scoring Systems

“…Furthermore, compared to that study, our cohort had considerably lower initial albumin levels and higher bilirubin levels, which indicated poor liver function. Similarly, in the initial reports on SAT and SEC, viral liver disease was the most common etiology, and liver function was considerably better in those cohorts than in our study cohort ( 13 , 20 ). In the original study on the SAT, the score outperformed the BCLC classification and the ALBI score in predictive ability.…”

“…Standardized cut-offs for the laboratory parameters were derived from our laboratory database. Cut-off values for TBS, SAT and SEC were adopted from the original publications ( 13 , 19 , 20 ). The distributions of patients, according to TBS SAT and SEC, were compared with the Chi-Square test for categorial variables.…”

“…A third novel scoring system, the Seven-Eleven criteria (SEC), was recently developed to estimate tumor burden ( 20 ). These criteria also include tumor size and the number of tumor nodes in the calculation.…”

Effect of Transarterial Chemoembolization on ALBI Grade in Intermediate-Stage Hepatocellular Carcinoma: Criteria for Unsuitable Cases Selection

“…Our recent ALBI-TAE model suggested that up-to-eleven criteria is more discriminative than up-to-seven criteria to predict survival after TACE [19,21], whereas six-twelve criteria can stratify recommended TACE candidates [22]. Most recently, we proposed seven-eleven criteria to redefine tumor burden, which can predict radiologic response and survival in HCC patients undergoing TACE [33]. Taking together, high tumor burden is agreed to be an important parameter to select TACE unsuitable patients [13,51,52].…”

“…During procedure, all target tumors were assessed by decreased antegrade tumor-feeding arterial flow. The embolization endpoint was reduced or no tumor stain along with subjective angiographic chemoembolization endpoint levels 2 and 3 [33].…”