Role of residual liver volumetry and function in prediction of liver tolerability after transarterial chemoembolization for hepatocellular carcinoma in cirrhotic patients: deriving a clinical decision support score

Background Transarterial chemoembolization (TACE) is the recommended treatment modality for non-resectable intermediate-stage hepatocellular carcinoma; however, this stage has wide variable levels of liver functions and tumor burden making a challenge as regards the tolerability of the functioning residual liver to this type of therapy. Further stratification of this intermediate stage may help the clinical decision for the suitability of TACE, so we tried to derive a clinical decision support tool to predict the tolerability of the functioning residual liver to TACE using pre-intervention liver reserve function and liver residual volume as well as tumor burden. Results Two hundred and fifty-two patients with non-resectable intermediate-stage hepatocellular carcinoma (HCC) were consecutively included in this cohort study; all patients were blindly followed up for 6 weeks after TACE for manifestation of liver decompensation. For univariate logistic regression analysis, the significant predictors were age, s.albumin, s.bilirubin, prothrombin concentration (PC), tumor volume (TV), residual liver volume (RLV), and residual to liver volumetric ratio (RLVR) (sig, 0.007, 0.000, 0.000, 0.000, 0.000, 0.002, and 0.000, respectively). Multivariate logistic regression analysis illustrated that s.albumin, s.bilirubin, PC, and RLVR were the most independent significant predictors (sig, 0.000 for all with adjusted OR 0.002, 22.692, 0.827, and 0.000, respectively). The discriminatory performance of our proposed decision support score (liver tolerability score) was evaluated using the receiver operating characteristics that identified two cutoff points (≤ 0.30 and ≥ 0.83) to rule out or rule in the possibility of liver decompensation after TACE, respectively (AUC, 0.942 and sig. 0.000). Liver tolerability score stratified the intermediate stage of HCC to 3 risk grades (low, medium, and high) with significant difference as regards hazard distribution. Conclusion Computed tomography image-based assessment of RLVR may have a possible role in predicting future tolerability of the functioning residual tissue to TACE of HCC. Liver tolerability score (LTS) could stratify the intermediate stage HCC to 3 risk grades, so LTS may have a role in clinical decision for the suitability of TACE for intermediate stage HCC.