The ART of decision making: Retreatment with transarterial chemoembolization in patients with hepatocellular carcinoma

Abstract

We aimed to establish an objective point score to guide the decision for retreatment with transarterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC). In all, 222 patients diagnosed with HCC and treated with multiple TACE cycles between January 1999 and December 2009 at the Departments of Gastroenterology/Hepatology of the Medical Universities of Vienna (training cohort) and Innsbruck (validation cohort) were included. We investigated the effect of the first TACE on parameters of liver function and tumor response and their impact on overall survival (OS, log rank test) and developed a point score (ART score: Assessment for Retreatment with TACE) in the training cohort (n 5 107, Vienna) by using a stepwise Cox regression model. The ART score was externally validated in an independent validation cohort (n 5 115, Innsbruck). The increase of aspartate aminotransferase (AST) by >25% (hazard ratio [HR] 8.4; P < 0.001), an increase of Child-Pugh score of 1 (HR 2.0) or !2 points (HR 4.4) (P < 0.001) from baseline, and the absence of radiologic tumor response (HR 1.7; P 5 0.026) remained independent negative prognostic factors for OS and were used to create the ART score. The ART score differentiated two groups (0-1.5 points; !2.5 points) with distinct prognosis (median OS: 23.7 versus 6.6 months; P < 0.001) and a higher ART score was associated with major adverse events after the second TACE (P 5 0.011). These results were confirmed in the external validation cohort and remained significant irrespective of ChildPugh stage and the presence of ascites prior the second TACE. Conclusion: An ART score of !2.5 prior the second TACE identifies patients with a dismal prognosis who may not profit from further TACE sessions. (HEPATOLOGY 2013;57:2261-2273

Hepatic Resection after Initial Transarterial Chemoembolization Versus Transarterial Chemoembolization Alone for the Treatment of Hepatocellular Carcinoma: A Meta-analysis of Observational Studies

“…Theoretically, there are some alternative approaches, such as repeated TACE, combined with sorafenib, followed by hepatic resection or RFA, or other promising drugs or procedures. First, the investigators from the Medical Universities of Vienna developed and validated the Assessment for Retreatment with TACE (ART) score in HCC patients to predict the necessity of repeated TACE (Sieghart et al, 2013). The ART score included radiologic tumor response and impairment of liver function (Child-Pugh score and aspartate aminotransferase) after the first TACE.…”

The problem of current classications of the hepatocellular carcinoma. Analytical review

“…Для отбора пациентов для продолжения ТАХЭ предла-гается две несложных в обращении шкалы, полученные с использованием регрессионной модели: «Оценка для по-вторного лечения ТАХЭ» (The Assessment for Retreatment with ТАСЕ) -ART, и шкала ABCR [64,65]. Шкала ART име-ет наибольшую оценку в баллах при повышении уровня ASAT (4 балла), а наименьшую -при выраженном ради-ологическом ответе (1 балл).…”

Usefulness of staging systems and prognostic scores for hepatocellular carcinoma treatments

“…After the first TACE: Two scores easy to calculate were proposed to improve the selection of patients before repeating the treatment: The Assessment for Retreatment with TACE (ART) and the ABCR scores, both defined using regression models [62,63] . The ART score associates its higher coefficient with a possible increase in ASAT levels (4 points), the lower being associated with the radiological response (1 point).…”