The ART Score Is Not Effective to Select Patients for Transarterial Chemoembolization Retreatment in an Italian Series

Abstract

Background: The ART score (a point score for the assessment of retreatment with transarterial chemoembolization, TACE) has been recently developed in Austria to differentiate patients who may benefit from multiple sessions of TACE for hepatocellular carcinoma (HCC) treatment. The primary aim of the study was to test the validity of the ART score in an Italian study cohort. The secondary aims were to evaluate overall survival (OS) and clinical determinants of improved survival in patients treated with multiple TACE sessions. Methods: The ART score and the clinical outcome of 51 consecutive patients with HCC submitted to multiple TACE sessions from April 2002 to December 2009 were retrospectively analyzed. Results: Median OS was 26.0 months (95% confidence interval 18.4-33.6) with 1-, 3- and 5-year survival rates of 75, 33 and 11%, respectively). Thirty-three patients had an ART score of 0-1.5 and in 18 it was ≥2.5, but in our patient series, the ART score was not found to be a predictor of survival (p = 0.173). At univariate analysis, tumor extent (uni- vs. bilobar: 34.0 vs. 9.0 months; p < 0.001), Child-Pugh score before the second TACE (A vs. B7 vs. B8-9: 26.0 vs. 16.0 vs. 5.0 months; p = 0.005) and Child-Pugh score increase between the first and second TACE (absent vs. + 1 point vs. + ≥2 points: 27.0 vs. 4.0 vs. 5.0 months; p < 0.001) were statistically related with survival. At multivariate analysis, only Child-Pugh score increase remained a significant predictor of worse survival (p = 0.001, hazard rate = 11.6). Conclusions: The ART score was not found to work as an objective tool to guide TACE retreatment in our Italian patient series, only the Child-Pugh score increase was an independent predictor of a shorter survival.

Patient Selection for Transarterial Chemoembolization in Hepatocellular Carcinoma: Importance of Benefit/Risk Assessment

“…Several studies have reported that the ART score was not a useful tool for guiding decisions on TACE retreatment. In an Italian retrospective analysis in 51 patients with HCC (BCLC stage A or B and Child-Pugh A or B), the ART score was not a significant predictor of survival [59]. A key difference between this study and the original ART score study was that patients may have had longer than 90 days between their first and second TACE, based on the clinical decision of the center.…”

Combined sequential use of HAP and ART scores to predict survival outcome and treatment failure following chemoembolization in hepatocellular carcinoma: a multi-center comparative study

“…These scores have been proposed as objective and mutually exclusive strategies to select patients for initial as well as subsequent loco-regional therapies based on their capacity to predict long-term survival following TACE. Their prognostic potential, however, has never been compared, a point of major consequence given the emergence of discrepancies from their independent evaluation in separate studies, which has lead to uncertainties in terms of which strategy should be prioritized for clinical use [14, 15]. …”

“…Whilst scientifically interesting, the relationship between these scores and patient's overall survival has been questioned following validation in independent cohorts, casting doubt upon their clinical utility [14, 15]. As a result, the use of either score is not advocated within the current management guidelines for HCC.…”

ART score and hepatocellular carcinoma: An appraisal of its applicability

“…According to another Italian report [21], ART score had no guidance on whether the patient should conduct TACE retreatment because there was no statistical difference on overall survival between patients with ART score of 0-1.5 and patients with ART scores ≥ 2.5 from their research population, which may be caused by the difference in research population and the relatively smaller number of patients (i.e., n = 51).…”