Surgical Resection is Better than Transarterial Chemoembolization for Patients with Hepatocellular Carcinoma Beyond the Milan Criteria: A Prognostic Nomogram Study.
BACKGROUND
The clinical outcomes in hepatocellular carcinoma (HCC) patients receiving surgical resection (SR) or transarterial chemoembolization (TACE) are diverse. This study aimed to develop a nomogram to predict individualized survival risk in patients with HCC beyond the Milan criteria undergoing aggressive treatments (SR and TACE).


METHODS
A total of 1009 patients were enrolled in the study and randomly grouped into derivation (n = 505) and validation sets (n = 504). The multivariate Cox proportional hazards model was used to select significant prognostic predictors from the derivation set to generate the nomogram. The performance of the nomogram was evaluated by discrimination (concordance index) and calibration tests.


RESULTS
Serum albumin <3.8 g/dL, α-fetoprotein ≥400 ng/mL, TACE, vascular invasion, multiple tumors, and tumor volume ≥200 cm(3) were associated with poor survival in the multivariate Cox model (all p < 0.05). A nomogram with a scale of 0-47 was developed with these six variables, and the predicted survival rates at 1 and 3 years were calculated. The derivation set with bootstrapping (B = 100) had a good concordance index of 0.694 [95% confidence interval (CI) 0.68-0.708]. Discrimination test in the validation set provided a concordance index of 0.71 (95 % CI 0.697-0.722), and the calibration plots well-matched the 45-degree line for 1- and 3-year survival prediction. The respective survival for patients undergoing SR or TACE could be predicted based on the nomogram across different risk scores.


CONCLUSIONS
This easy-to-use nomogram may accurately predict survival at 1 and 3 years for individual HCC patients beyond the Milan criteria, and provide quantitative survival advantage of SR over TACE.
Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.|Department of Internal Medicine, University of Nevada School of Medicine, Reno, NV, USA.|Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.
Chia-Yang
CY
Hsu
Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.|Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.
Po-Hong
PH
Liu
Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.|Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.
Cheng-Yuan
CY
Hsia
Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.|Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.
Yun-Hsuan
YH
Lee
Department of Pathology, University of Toronto, Toronto, ON, Canada.
Teddy S
TS
Nagaria
Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.|Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.
Rheun-Chuan
RC
Lee
Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.|Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.
Han-Chieh
HC
Lin
Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan. tihuo@vghtpe.gov.tw.|Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan. tihuo@vghtpe.gov.tw.|Institute of Pharmacology, National Yang-Ming University School of Medicine, Taipei, Taiwan. tihuo@vghtpe.gov.tw.
Teh-Ia
TI
Huo
D000368:Aged; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D006528:Carcinoma, Hepatocellular / Q000473:pathology / Q000601:surgery* / Q000628:therapy; D016461:Chemoembolization, Therapeutic; D003131:Combined Modality Therapy; D005260:Female; D005500:Follow-Up Studies; D006498:Hepatectomy; D006801:Humans; D008113:Liver Neoplasms / Q000473:pathology / Q000601:surgery* / Q000628:therapy; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D049451:Nomograms; D011379:Prognosis; D057216:Propensity Score; D011446:Prospective Studies; D012189:Retrospective Studies; D015996:Survival Rate