Patients with unresectable hepatocellular carcinoma (HCC) treated with conventional transarterial chemoembolization (cTACE) have heterogeneous tumor burden and liver function. Therefore, the selection of patients for repeated cTACE is challenging owing to different outcomes. This study aimed to establish a decision-making scoring system for repeated cTACE to guide further treatment.
All HCC patients who underwent cTACE between 2008 and 2019 were included and randomly assigned into training (n = 324) and validation (n = 162) cohorts. Tumor size, number of masses, Albumin-Bilirubin score, baseline Alpha-fetoprotein level, and response to initial cTACE session were selected to generate a “SMAART” score in the training cohort. Patients were stratified according to the SMAART score: low risk, 0‒2; medium risk, 3‒4; and high risk, 5‒8. Prediction error curves based on the integrated Brier score (IBS) and the Harrell C-index validated the SMAART scores and compared them to the Assessment for Retreatment with Transarterial chemoembolization (ART) scores.
The low-risk group had the longest median overall survival of 39.0 months followed by the medium- and high-risk groups of 21.2 months and 10.5 months, respectively, with significant differences (P < 0.001). The validation cohort had similar results. The high-risk group had 63.1% TACE-refractory cases. The Harrell C-indexes were 0.562 and 0.665, and the integrated Brier scores were 0.176 and 0.154 for the ART and SMAART scores, respectively.
SMAART score can aid clinicians in selecting appropriate candidates for subsequent cTACE. A SMAART score ≥5 after the first cTACE session identified patients with poor prognosis who may not benefit from additional cTACE session.