title: Validation of the Risk Prediction Models STATE-Score and START-Strategy to Guide TACE Treatment in Patients with Hepatocellular Carcinoma.
abstract: OBJECTIVE
  Several scoring systems that guide patients' treatment regimen for transarterial chemoembolization (TACE) of hepatocellular carcinoma (HCC) have been introduced, but none have gained widespread acceptance in clinical practice. The purpose of this study is to externally validate the Selection for TrAnsarterial chemoembolization TrEatment (STATE)-score and START-strategy [i.e., sequential use of the STATE-score and Assessment for Retreatment with TACE (ART)-score].
  
  
  METHODS
  From January 2000 to September 2015, 933 patients with HCC underwent TACE at our institution. All variables needed to calculate the STATE-score and implement the START-strategy were determined. STATE comprised serum albumin, up-to-seven criteria, and C-reactive protein (CRP). ART comprised an increase in aspartate aminotransferase, the Child-Pugh score, and a radiological tumor response. Overall survival was calculated, and multivariate analysis performed. In addition, the STATE-score and START-strategy were validated using the Harrell's C-index and integrated Brier score (IBS).
  
  
  RESULTS
  The STATE-score was calculated in 228 patients. Low and high STATE-scores corresponded to median survival of 14.3 and 20.2 months, respectively. Harrell's C was 0.558 and IBS 0.133. For the STATE-score, significant predictors of survival were up-to-seven criteria (p = 0.006) and albumin (p = 0.022). CRP values were not predictive (p = 0.367). The ART-score was calculated in 207 patients. Combining the STATE-score and ART-score led to a Harrell's C of 0.580 and IBS of 0.132.
  
  
  CONCLUSIONS
  The STATE-score was unable to reliably determine the suitability for initial TACE. The START-strategy only slightly improved the predictive ability compared to the ART-score alone. Therefore, neither the STATE-score nor START-strategy alone provides sufficient certainty for clear-cut clinical decisions.
authors.affiliation: Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg University, Langenbeckst. 1, 55131, Mainz, Germany. aline.maehringer-kunz@unimedizin-mainz.de.
authors.forename: Aline
authors.initials: A
authors.lastname: Mähringer-Kunz
authors.affiliation: Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg University, Langenbeckst. 1, 55131, Mainz, Germany.
authors.forename: Roman
authors.initials: R
authors.lastname: Kloeckner
authors.affiliation: Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg University, Langenbeckst. 1, 55131, Mainz, Germany.
authors.forename: Michael B
authors.initials: MB
authors.lastname: Pitton
authors.affiliation: Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg University, Langenbeckst. 1, 55131, Mainz, Germany.
authors.forename: Christoph
authors.initials: C
authors.lastname: Düber
authors.affiliation: Institute of Medical Biostatistics, Epidemiology and Informatics, Johannes Gutenberg University, Obere Zahlbacher St. 69, 55131, Mainz, Germany.
authors.forename: Irene
authors.initials: I
authors.lastname: Schmidtmann
authors.affiliation: Department of Internal Medicine, University Medical Center of the Johannes Gutenberg University, Langenbeckst. 1, 55131, Mainz, Germany.
authors.forename: Peter R
authors.initials: PR
authors.lastname: Galle
authors.affiliation: Department of Internal Medicine, University Medical Center of the Johannes Gutenberg University, Langenbeckst. 1, 55131, Mainz, Germany.|Clinical Registry Unit (CRU), University Medical Center of the Johannes Gutenberg University, Langenbeckst. 1, 55131, Mainz, Germany.
authors.forename: Sandra
authors.initials: S
authors.lastname: Koch
authors.affiliation: Department of Internal Medicine, University Medical Center of the Johannes Gutenberg University, Langenbeckst. 1, 55131, Mainz, Germany.|Clinical Registry Unit (CRU), University Medical Center of the Johannes Gutenberg University, Langenbeckst. 1, 55131, Mainz, Germany.
authors.forename: Arndt
authors.initials: A
authors.lastname: Weinmann
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D006528:Carcinoma, Hepatocellular / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D016461:Chemoembolization, Therapeutic / Q000379:methods*; D003661:Decision Support Techniques; D005260:Female; D006801:Humans; D008111:Liver Function Tests; D008113:Liver Neoplasms / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D015233:Models, Statistical; D019233:Retreatment; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods* / Q000706:statistics & numerical data; D016019:Survival Analysis; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
keywords: ART-score; Hepatocellular carcinoma; START-strategy; STATE-score; Transarterial chemoembolization