title: How to STATE suitability and START transarterial chemoembolization in patients with intermediate stage hepatocellular carcinoma.
abstract: OBJECTIVE
  We aimed to establish an objective point score to guide the decision for the first treatment with transarterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC).
  
  
  METHODS
  277 patients diagnosed with HCC and treated with transarterial treatments between 1/2002 and 12/2011 at the Medical Universities of Vienna (training cohort) and Innsbruck (validation cohort) were included. We investigated the impact of baseline liver function and tumour load on overall survival (OS, log-rank test) and developed a point score (STATE-score: Selection for TrAnsarterial chemoembolisation TrEatment) in the training-cohort (n=131, Vienna) by using a stepwise Cox regression model. The STATE-score was externally validated in an independent validation cohort (n=146, Innsbruck) and thereafter combined with the Assessment for Retreatment with TACE (ART)-score to identify patients who are (un)suitable for TACE.
  
  
  RESULTS
  The STATE-score starts with the serum-albumin level (g/L), which is reduced by 12 points each, if the tumour load exceeds the up-to-7 criteria and/or C-reactive protein (CRP) levels are ⩾1 mg/dl (maximum reduction: 24 points). The STATE-score differentiated 2 groups (<18, ⩾18 points) with distinct prognosis (median OS: 5.3 vs. 19.5 months; p<0.001) and a lower STATE-score was associated with short-term harm and increased mortality after TACE-1 (39% vs. 14% p<0.001). Sequential use of the STATE and the ART-score (START-strategy) identified the most (un)suitable patients for TACE. Results were confirmed in the external validation-cohort and were independent from recently proposed baseline selection tools.
  
  
  CONCLUSIONS
  The STATE-score identifies patients who are (un)suitable for the first TACE. The START-strategy identified the best candidates for multiple TACE sessions.
authors.affiliation: Division of Gastroenterology and Hepatology, Department of Internal Medicine III, AKH & 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 & Medical University of Vienna, Austria.
authors.forename: Matthias
authors.initials: M
authors.lastname: Pinter
authors.affiliation: Department of Gastroenterology and Hepatology, LKH & Medical University of Innsbruck, Austria.
authors.forename: Ivo
authors.initials: I
authors.lastname: Graziadei
authors.affiliation: Division of Gastroenterology and Hepatology, Department of Internal Medicine III, AKH & Medical University of Vienna, Austria.
authors.forename: Simona
authors.initials: S
authors.lastname: Bota
authors.affiliation: Department of Gastroenterology and Hepatology, LKH & 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 & 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, 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 & 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 & Medical University of Vienna, Austria.
authors.forename: Markus
authors.initials: M
authors.lastname: Peck-Radosavljevic
authors.affiliation: Division of Gastroenterology and Hepatology, Department of Internal Medicine III, AKH & Medical University of Vienna, Austria. Electronic address: wolfgang.sieghart@meduniwien.ac.at.
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Sieghart
mesh_terms: D000368:Aged; D000970:Antineoplastic Agents / Q000008:administration & dosage*; D002097:C-Reactive Protein / Q000378:metabolism; D006528:Carcinoma, Hepatocellular / Q000378:metabolism / Q000401:mortality / Q000628:therapy*; D016461:Chemoembolization, Therapeutic / Q000379:methods*; D015331:Cohort Studies; D005260:Female; D006801:Humans; D008113:Liver Neoplasms / Q000378:metabolism / Q000401:mortality / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D012044:Regression Analysis; D012189:Retrospective Studies; D012709:Serum Albumin / Q000378:metabolism; D015996:Survival Rate; D016896:Treatment Outcome
chemical_list: D000970:Antineoplastic Agents; D012709:Serum Albumin; D002097:C-Reactive Protein
keywords: ART-score; HCC; Hepatocellular carcinoma; Prognosis; TACE