A Novel Stratification Scheme Combined with Internal Arteries in CT Imaging for Guiding Postoperative Adjuvant Transarterial Chemoembolization in Hepatocellular Carcinoma: A Retrospective Cohort Study

Hepatobiliary System Medicine Oncology Medical Imaging
CT imaging hepatectomy hepatocellular carcinoma prognosis transarterial chemoembolization

Retrospective Cohort Study on Innovative Stratification Scheme Based on Postoperative Combined CT Imaging to Guide Postoperative Adjuvant Transarterial Chemoembolization for Hepatocellular Carcinoma

Background

Hepatocellular carcinoma (HCC) is the sixth most common cancer globally and the fourth leading cause of cancer-related deaths. For HCC, liver resection is the main treatment method, especially in the early stages, but the 5-year recurrence rate after surgery remains as high as 50-75%. Studies have shown that postoperative adjuvant transarterial chemoembolization (PA-TACE) can prolong the long-term survival and reduce the tumor recurrence rate in some HCC patients. However, there is a controversy over the efficacy of PA-TACE, with some studies failing to demonstrate its effects, making the selection of suitable patients an urgent issue.

High-risk patients with microvascular invasion (MVI), tumor diameter greater than 5 cm, and multinodular disease are considered potential beneficiaries of PA-TACE, but there is currently no unified standard. Some existing methods for predicting the efficacy of PA-TACE require additional testing steps, increasing the economic burden on patients and the workload of doctors. Contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) are the preferred imaging examinations for the diagnosis of HCC. Based on this, this study hypothesizes that imaging features can help identify which patients will benefit from PA-TACE and proposes a new scheme based on CT imaging features to guide PA-TACE treatment.

Research Objectives and Methods

This research was mainly conducted by a team of experts from the People’s Hospital of Guangdong Province (Southern Medical University) and the Cancer Center of Sun Yat-sen University, and was published online in the International Journal of Surgery on February 21, 2024.

Through a retrospective analysis, the study included HCC patients who underwent liver resection at the Cancer Center of Sun Yat-sen University and Zhujiang Hospital of Southern Medical University. Based on computed tomography (CT) imaging features, a new stratification scheme was developed to guide PA-TACE treatment. The study selected cases from January 2012 to December 2020, and exclusion criteria included preoperative treatment, intraoperative or postoperative death, and imaging artifacts.

Research Process and Methods

The research process can be broadly divided into the following steps:

  1. Patient Screening and Inclusion Criteria: Eligible patients were required to undergo CT scanning within one month before surgery and be pathologically diagnosed with HCC. The study excluded cases with previous tumor treatment, major vascular thrombosis or metastasis, and imaging artifact interference.

  2. Data Analysis and Statistical Methods: Inverse probability of treatment weighting (IPTW) was used to adjust for baseline characteristic differences, and the Cox proportional hazards model was used to analyze the interactions between PA-TACE and imaging features, pathological indicators. Data was visualized using tools such as forest plots and funnel plots, with an interaction significance p-value <0.10 considered significant.

  3. Imaging Analysis: For each HCC case, imaging features (such as tumor diameter, number of nodules, presence of internal arteries, etc.) were evaluated, and an HCC Imaging and Pathological Classification (HIPC) scheme was established by integrating imaging features and pathological indicators.

Main Research Results

  1. Patient Characteristics and Survival Analysis: The study included 1,488 patients (average age 52 years) with a median follow-up of 6 years. After IPTW adjustment, all baseline characteristic differences were within 0.1. Overall, the PA-TACE group had a higher recurrence-free survival rate (RFS), while the overall survival rate (OS) was similar.

  2. Subgroup and Interaction Analysis: MVI-positive patients showed significant benefits after PA-TACE (HR, 0.656), while MVI-negative patients did not show significant benefits. Patients with positive internal arteries (IA) also showed significant benefits in RFS and OS. By incorporating IA into the original risk stratification, the prediction of PA-TACE efficacy was further refined.

  3. HIPC Scheme Validation: By integrating imaging and pathological features, the HIPC scheme classified patients into three groups (HIPC1 low risk, HIPC2 moderate risk, HIPC3 high risk). Compared to the conventional postoperative recommendation, the new scheme can reduce approximately 36.5% of PA-TACE treatment patients, thereby avoiding unnecessary side effects.

  4. Clinical Significance and Importance: The HIPC scheme not only provides reliable guidance for PA-TACE treatment from an imaging perspective but also reduces unnecessary treatment, improving the accuracy of clinical decision-making.

Conclusions and Significance

This study demonstrated that the presence of internal arteries is an important imaging biomarker for predicting the efficacy of PA-TACE and proposed a new PA-TACE guidance stratification scheme (HIPC). This scheme integrates CT imaging and pathological features, allowing for individualized patient selection through imaging modalities before surgery and improving the accuracy of postoperative adjuvant treatment. In the future, this scheme holds promise as an important tool for guiding PA-TACE treatment in HCC patients and encourages further exploration of the potential of new imaging features for clinical decision-making.