Wei Xu,1,* Xia Ding,2,* Yan Xu,3 Yongchuang Zhang,1 Huaxiao Xu,1 Lin Guo,1 Lei Li1 

1Department of Interventional Radiology, Qingdao Central Hospital, University of Health and Rehabilitation Sciences (Qingdao Central Hospital), Qingdao, Shandong, 266042, People’s Republic of China; 2Department of Oncology, Qingdao Hospital, University of Health and Rehabilitation Sciences (Qingdao Municipal Hospital), Qingdao, Shandong, 266071, People’s Republic of China; 3Department of Oncology, Qingdao Central Hospital, University of Health and Rehabilitation Sciences (Qingdao Central Hospital), Qingdao, Shandong, 266042, People’s Republic of China

*These authors contributed equally to this work

Correspondence: Lei Li, Department of Interventional Radiology, Qingdao Central Hospital, University of Health and Rehabilitation Sciences(Qingdao Central Hospital), Qingdao, Shandong, 266042, People’s Republic of China, Email 369542019@qq.com

Background: Surgical resection (SR) following transarterial chemoembolization (TACE) is a promising option for large hepatocellular carcinoma (LHCC) with HBV, and identification of these patients at high-risk of prognosis may help individualized treatment.
Purpose: To develop and validate pre- and postoperative prognostic nomograms integrating clinico-therapeutic-pathological features for predicting overall survival (OS) after TACE combined therapy.
Materials and Methods: Between May 2010 and October 2021, 255 consecutive patients with LHCC receiving conversion therapy of TACE combined with Lenvatinib plus PD-1 inhibitors were included from three tertiary-care hospitals. In the derivation cohort (n=201), the Cox regression analysis for developing nomograms for OS (time from initial TACE to death). In the testing cohort (n = 54), two models’ performance was compared with five major staging systems.
Results: The preoperative nomogram included alpha–fetoprotein (AFP, HR: 0.486; 95% CI: 0.266– 0.886; P = 0.019) and albumin- bilirubin (ALBI) grade (HR: 0.323; 95% CI: 0.181– 0.578; P < 0.001) and the postoperative nomogram, included AFP (HR: 0.501; 95% CI: 0.271– 0.925; P = 0.027), ALBI grade (HR: 0.356; 95% CI: 0.192– 0.659; P = 0.001), MVI (HR: 0.086; 95% CI: 0.024– 0.192; P < 0.001), and response to TACE combined therapy (HR: 3.367; 95% CI: 1.479– 7.721; P = 0.004). The testing dataset C-indexes of the pre- (0.715) and postoperative (0.912) nomograms were higher than all five staging systems (0.589– 0.483; all P < 0.001). Two prognostically distinct risk strata were identified according to these nomograms (all P < 0.001).
Conclusion: Based on 255 patients receiving TACE combined conversion therapy for LHCC, we developed and validated two nomograms for predicting OS, with superior performances than five major staging systems and effective survival stratification.

Keywords: hepatocellular carcinoma, transarterial chemoembolization, conversion therapy, surgical resection, nomogram