title: The ART-strategy: sequential assessment of the ART score predicts outcome of patients with hepatocellular carcinoma re-treated with TACE.
abstract: OBJECTIVE
  Recently, we developed the ART score (assessment for re-treatment with TACE) to guide the decision for a second transarterial chemoembolization (TACE-2) in patients with hepatocellular carcinoma (HCC). Patients with an ART score of 0-1.5 points gained benefit from a second TACE session, while patients with an ART score ≥2.5 points did not. Here, we investigated (1) the prognostic significance of the ART score prior to the third (TACE-3) and fourth TACE (TACE-4), and (2) the feasibility of an ART score guided re-treatment strategy by sequential assessment of the ART score in HCC patients treated with multiple TACE sessions.
  
  
  METHODS
  109 patients, diagnosed with intermediate stage HCC and treated with ≥3 TACE sessions between January 1999 and December 2009 at the Medical Universities of Vienna and Innsbruck, were included. The ART score prior to each TACE session was assessed in comparison to the TACE naïve liver. The prognostic performance of the ART score before TACE-3 and 4 was evaluated with and without stratification based on the ART score prior to the respective last intervention.
  
  
  RESULTS
  The pre-TACE-3 ART score discriminated two groups with different prognosis and remained a valid predictor of OS independent of Child-Pugh score (5-7 points), CRP-levels and tumor characteristics. Even in patients with an initially beneficial ART score (0-1.5 points) before TACE-2, repeated ART score assessment before TACE-3 identified a subgroup of patients with dismal prognosis (median OS: 27.8 vs. 10.8 months, p<0.001). Similar results were observed when the ART score was applied before TACE-4.
  
  
  CONCLUSIONS
  The sequential assessment of the ART score identifies patients with dismal prognosis prior to each TACE session.
authors.affiliation: Division of Gastroenterology and Hepatology, Department of Internal Medicine III, AKH and Medical University of Vienna, Austria.
authors.forename: Florian
authors.initials: F
authors.lastname: Hucke
authors.affiliation: Division of Gastroenterology and Hepatology, Department of Internal Medicine III, AKH and Medical University of Vienna, Austria. Electronic address: wolfgang.sieghart@meduniwien.ac.at.
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Sieghart
authors.affiliation: Division of Gastroenterology and Hepatology, Department of Internal Medicine III, AKH and Medical University of Vienna, Austria.
authors.forename: Matthias
authors.initials: M
authors.lastname: Pinter
authors.affiliation: Department of Gastroenterology and Hepatology, LKH and Medical University of Innsbruck, Austria.
authors.forename: Ivo
authors.initials: I
authors.lastname: Graziadei
authors.affiliation: Department of Gastroenterology and Hepatology, LKH and Medical University of Innsbruck, Austria.
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Vogel
authors.affiliation: Division of Gastroenterology and Hepatology, Department of Internal Medicine III, AKH and Medical University of Vienna, Austria.
authors.forename: Christian
authors.initials: C
authors.lastname: Müller
authors.affiliation: Section for Clinical Biometrics, Medical University of Vienna, Austria.
authors.forename: Harald
authors.initials: H
authors.lastname: Heinzl
authors.affiliation: Department of Interventional Radiology, AKH and Medical University of Vienna, Austria.
authors.forename: Fredrik
authors.initials: F
authors.lastname: Waneck
authors.affiliation: Division of Gastroenterology and Hepatology, Department of Internal Medicine III, AKH and Medical University of Vienna, Austria.
authors.forename: Michael
authors.initials: M
authors.lastname: Trauner
authors.affiliation: Division of Gastroenterology and Hepatology, Department of Internal Medicine III, AKH and Medical University of Vienna, Austria. Electronic address: markus.peck@meduniwien.ac.at.
authors.forename: Markus
authors.initials: M
authors.lastname: Peck-Radosavljevic
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002097:C-Reactive Protein / Q000032:analysis; D006528:Carcinoma, Hepatocellular / Q000401:mortality / Q000628:therapy*; D016461:Chemoembolization, Therapeutic / Q000379:methods*; D005260:Female; D006801:Humans; D008113:Liver Neoplasms / Q000401:mortality / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D016016:Proportional Hazards Models; D016896:Treatment Outcome
chemical_list: D002097:C-Reactive Protein
keywords: ART score; HCC; Hepatocellular carcinoma; Prognosis; TACE