Conventional transarterial chemoembolization vs microsphere embolization in hepatocellular carcinoma: A meta-analysis

AIM:To compare conventional transarterial chemoembolization(c-TACE)with microsphere embolization in hepatocellular carcinoma(HCC).METHODS:We searched Pub Med,Medline,Embase and the Cochrane Library for trials assessing the efficacy and safety of c-TACE in comparison with those of yttrium-90 microsphere or drug-eluting bead embolization from January 2004 to December 2013.Overall survival rate(OSR),tumor response[complete response,partial response(PR),stable disease(SD),progressive disease(PD)],α-fetoprotein(AFP)response,progression rate and complications were compared and analyzed.Pooled ORs with 95%CI were calculated using either the fixed-effects model or random-effects model.All statistical analyses were conducted using the Review Manager(version 5.1.)from the Cochrane collaboration.RESULTS:Thirteen trials were identified,including a total of 1834 patients;1233 were treated with c-TACE,377 underwent yttrium-90 microsphere embolization and 224 underwent drug-eluting bead embolization.The meta-analysis with either the random-effects model or fixed-effects model indicated that microsphere embolization was associated with significantly higher OSRs compared with those of c-TACE(OR1-year=1.38,95%CI1-year:1.05-1.82;OR2-year=2.88,95%CI2-year:1.18-7.05;OR3-year=2.15,95%CI3-year:1.18-3.91).The complete tumor response rates of patients who underwent microspheres embolization were significantly higher than those of patients treated with c-TACE(OR=2.19,95%CI:1.31-3.64).The tumor progression rate after microsphere embolization was markedly lower than that after c-TACE(OR=0.56,95%CI:0.39-0.81).There was no significant difference between microsphere embolization and c-TACE in PR(OR=0.73,95%CI:0.47-1.15),SD(OR=1.07,95%CI:0.79-1.44),PD(OR=0.75,95%CI:0.33-1.68),AFP response(OR=1.38,95%CI:0.64-2.94)and complications(OR=0.68,95%CI:0.46-1.00).CONCLUSION:Our analysis indicated that microsphere embolization was associated with superior survival and treatment response in comparison with c-TACE in the treatment of patients with HCC.     

Antibiotic prophylaxis in transarterial chemoembolization of hepatocellular carcinoma

Background and study aims

Transarterial chemoembolization remains a common treatment option in unresectable hepatocellular carcinoma. However, protocols for pre- and post-procedure care and the role of antibiotic prophylaxis have not been evaluated. The aim of this work was to compare 3 different groups of prophylactic antibiotics in patients undergoing chemoembolization and to compare the efficacy of intravenous versus oral route.

Predictive factors of transarterial chemoembolisation toxicity in unresectable hepatocellular carcinoma

BackgroundTransarterial chemoembolisation (TACE) is an effective treatment for unresectable hepatocellular carcinoma (HCC), but can cause severe toxicity.AimTo identify predictive factors of severe TACE-related toxicity in patients with unresectable HCC.MethodsAll HCC patients who underwent TACE at the Dijon University Hospital between 2008 and 2011 were included in this retrospective study. Severe TACE-related toxicity was defined as the occurrence of any adverse event grade ≥4, or any adverse event that caused a prolongation of hospitalisation of >8 days, or any additional hospitalisation within 1 month after TACE. Factors predicting toxicity were identified using a logistic regression model. The robustness of the final model was confirmed using bootstrapping (500 replications).Results124 patients were included, median age was 67 years and 90% were male; 22 patients (18%) experienced severe TACE-related toxicity. Factors that independently predicted severe TACE-related toxicity in multivariate analysis were total tumour size (OR, 1.15 cm⁻¹; 95%CI, 1.04–1.26; p = 0.01), and high serum AST levels (OR, 1.10 per 10 IU/l; 95%CI, 1.01–1.21; p = 0.04). The results were confirmed by bootstrapping.ConclusionsTotal tumour size and high serum AST levels were predictive factors of severe TACE-related toxicity in this hospital-based series of patients with unresectable HCC.     

High rate of complete histopathological response in hepatocellular carcinoma patients after combined transarterial chemoembolization and stereotactic body radiation therapy

BACKGROUNDLiver transplantation (LT) presents a curative treatment option in patients with early stage hepatocellular carcinoma (HCC) who are not eligible for resection or ablation therapy. Due to a risk of up 30% for waitlist drop-out upon tumor progression, bridging therapies are used to halt tumor growth. Transarterial chemoembolization (TACE) and less commonly stereotactic body radiation therapy (SBRT) or a combination of TACE and SBRT, are used as bridging therapies in LT. However, it remains unclear if one of those treatment options is superior. The analysis of explant livers after transplantation provides the unique opportunity to investigate treatment response by histopathology.AIMTo analyze histopathological response to a combination of TACE and SBRT in HCC in comparison to TACE or SBRT alone. METHODSIn this multicenter retrospective study, 27 patients who received liver transplantation for HCC were analyzed. Patients received either TACE or SBRT alone, or a combination of TACE and SBRT as bridging therapy to liver transplantation. Liver explants of all patients who received at least one TACE and/or SBRT were analyzed for the presence of residual vital tumor tissue by histopathology to assess differences in treatment response to bridging therapies. Statistical analysis was performed using Fisher-Freeman-Halton exact test, Kruskal-Wallis and Mann-Whitney-U tests.RESULTSFourteen patients received TACE only, four patients SBRT only, and nine patients a combination therapy of TACE and SBRT. There were no significant differences between groups regarding age, sex, etiology of underlying liver disease or number and size of tumor lesions. Strikingly, analysis of liver explants revealed that almost all patients in the TACE and SBRT combination group (8/9, 89%) showed no residual vital tumor tissue by histopathology, whereas TACE or SBRT alone resulted in significantly lower rates of complete histopathological response (0/14, 0% and 1/4, 25%, respectively, P value < 0.001). CONCLUSIONOur data suggests that a combination of TACE and SBRT increases the rate of complete histopathological response compared to TACE or SBRT alone in bridging to liver transplantation.     

重症急性胰腺炎预防性抗生素治疗的荟萃分析

目的通过对有关文献的荟萃分析,探讨预防性抗生素治疗在重症急性胰腺炎(SAP)中的作用。方法检索1966年到2004年8月期间发表的有关预防性抗生素治疗SAP的作用方面的随机对照临床试验(RCT)。按照人选标准,有6项临床试验纳入本研究,由2名作者各自独立地对入选研究中有关试验设计、研究对象的特征、研究结果等内容进行摘录,并用RevMan4.2软件进行分析。结果在SAP患者中,使用能在胰腺组织中达到有效浓度的广谱抗生素并不能减少胰腺感染(RR=0.77,95% 可信区间为0.48-1.24,P=0.28),也不能减少手术干预(RR=0.84,95%可信区间为0.40-1.74, P=0.64),更不能降低死亡率(RR=0.54,95%可信区间为0.28-1.04,P=0.07),只有胰外感染的发生率有一定的减少(RR=0.52,95%可信区间为0.31-0.88,P=0.01)。结论不建议在SAP患者中不加选择地预防性使用抗生素,但对于CT证实的坏死性胰腺炎,可以考虑抗生素预防性治疗。     

Increased extrinsic apoptotic pathway activity in patients with hepatocellular carcinoma following transarterial embolization

AIM:To determine the apoptosis pathway in residualviable hepatocellular carcinoma(HCC) tissues followingtransarterial embolization(TAE) .METHODS:Ten patients with HCC who received sur-gical resection after TAE were enrolled in the study group,and 24 patients with HCC who received surgical resection only served as the control group. In thestudy group,we measured the changes in tumor sizeand α fetoprotein(AFP) levels after TAE. All tissuesamples were taken from the residual tumors. The ex-pression of various ...     

Review of preoperative transarterial chemoembolization for resectable hepatocellular carcinoma

Hepatocellular carcinoma(HCC) is one of the few cancers whose incidence has been continually increasing over recent years.Resection of HCC offers the only hope for cure.However,recurrences are common in patients who have undergone resection.In our opinion,the effectiveness with which transarterial chemoembolization(TACE) as a neoadjuvant therapy for resectable HCC prevents recurrence and prolongs survival has not been conclusively demonstrated.All published meta-analyses have consistently failed to demonstrate that preoperative TACE improves the prognosis of resectable HCC.We believe that these published articles have several limitations and have our own views about the results of meta-analyses.It is very important that the scientific community shed more light on the pathogenesis of HCC and relate this to choice of therapy.This review mainly concerns our understanding of preoperative TACE for resectable HCC and briefly addresses desirable directions for future studies.     

Comparison of hepatic resection and transarterial chemoembolization for solitary hepatocellular carcinoma

AIM: To compare the outcomes of hepatic resection and transarterial chemoembolization (TACE) for solitary hepatocellular carcinoma (HCC) according to the Barcelona Clinic Liver Cancer (BCLC) staging system.METHODS: A consecutive sample of 540 patients with solitary HCC who underwent liver resection (n = 312) or TACE (n = 128) were included in the present study. Baseline characteristics, tumor characteristics, and post-operative complications were compared between the two groups. The Kaplan-Meier method was used for long-term survival analysis. Independent prognostic predictors were identified using the Cox proportional hazards model (univariate and multivariate analyses).RESULTS: The TACE and liver resection groups had similar baseline demographic and clinicopathological characteristics. The TACE group showed a significantly lower rate of major complications than the liver resection group (3.9% vs 17.4%, P < 0.001). Univariate and multivariate analyses indicated that TACE did not contribute to poor overall survival compared with liver resection; however, a solitary tumor diameter of greater than 6 cm should be considered a risk factor for poor overall survival (HR = 1.328, 95%CI: 1.002-1.783, P = 0.048). The liver resection and TACE groups had comparable overall survival rates at 1 year, 3 years, and 5 years (86.2%, 62.8%, and 44.0% vs 88.3%, 59.8%, and 40.6%, respectively, P = 0.419). In cases with tumor diameters equal to or less than 6 cm, the liver resection group showed a survival benefit compared with the TACE group at 1 year, 3 years, and 5 years (P = 0.030). The 1-, 3-, and 5-year overall survival rates of HCC cases with tumor diameters of more than 6 cm were similar among the liver resection and TACE groups (P = 0.467).CONCLUSION: A tumor diameter of 6 cm should be the cutoff for deciding between liver resection and TACE.     

Randomised controlled trial of lipiodol transarterial chemoembolisation with or without amiodarone for unresectable hepatocellular carcinoma

Background

There is no consensus about the most effective method for transarterial chemoembolisation of hepatocellular carcinoma.

Aim

The aim of this phase II trial was to compare the efficacy and toxicity of lipiodol transarterial chemoembolisation with amiodarone in association with pirarubicin or doxorubicin versus lipiodol transarterial chemoembolisation with anthracycline alone in a control group.

Methods

Patients with unresectable hepatocellular carcinoma and Child-Pugh A/B7 were considered eligible for the trial. transarterial chemoembolisation was repeated every 6 weeks for a maximum of 4 sessions.

Results

Thirteen patients were randomised in the amiodarone group, and 14 were randomised in the control group. The two groups were comparable with respect to their baseline characteristics. The objective response rate according to the EASL criteria was 62% (95% CI 35–88) in the amiodarone group and 50% (95% CI 24–76) in the control group. At 1 and 2 years, survival rates were 77% (95% CI 44–92) and 52% (95% CI 22–75) in the amiodarone group, and 57% (95% CI 28–78) and 40% (95% CI 15–65) in the control group, respectively. There was no difference between the two groups in terms of toxicity.

Conclusions

The results of this study suggest that lipiodol transarterial chemoembolisation with anthracycline and amiodarone was safe but did not increase survival compared with lipiodol transarterial chemoembolisation with anthracycline alone in patients with hepatocellular carcinoma.     

Chemotherapy for transarterial chemoembolization in patients with unresectable hepatocellular carcinoma

AIM: To compare the efficacy of different chemotherapeutic agents during conventional transarterial chemoembolization (cTACE) in the treatment of unresectable hepatocellular carcinoma (HCC).METHODS: A retrospective review was undertaken of patients with unresectable HCC undergoing cTACE from May 2003 to November 2011. A total of 107 patients were treated with at least one cTACE session. Irinotecan (CPT-11) was used as a chemotherapeutic agent in 24 patients, gemcitabine (GEM) in 24 and doxorubicin in 59.RESULTS: The time to progression and overall survival rates were significantly superior in patients treated with CPT-11 compared with the GEM or doxorubicin treated groups (11.4, 8.2, 9.5 mo, P = 0.02 and 21.7, 12.7, 14.5 mo, P = 0.004, respectively). Subgroup analysis showed that for intermediate-stage HCC, CPT-11 resulted in a significantly longer time to progression and overall survival compared with the GEM or doxorubicin treated groups (P = 0.022; P = 0.003, respectively). There were no significant differences in adverse events among the three groups (P > 0.05).CONCLUSION: For patients treated with cTACE, the chemotherapeutic agent CPT-11 was significantly associated with improved overall survival and delayed tumor progression compared with GEM or doxorubicin. There were no significant differences in clinical adverse events between the three agents. CPT-11 thus appears to be a promising agent when combined with cTACE for the treatment of HCC.     

Impact of pre-operative transarterial embolization on the treatment of hepatocellular carcinoma with liver transplantation

AIM: To determine the effectiveness of pre-liver transplant (LT) transarterial embolization (TAE) in treating hepatocellular carcinoma (HCC) and the patient categories, which are likely to have a good outcome after LT. METHODS: Twenty-nine patients with hepatitis-related cirrhosis and unresectable HCC after LT were studied over a 7-year period. The patients were divided into two groups: group A patients (19/29) received pre-LT TAE, whereas group B (10/29) underwent LT without prior TAE. According to Milan criteria, group A patients were further subdivided into: group A1(12/19) who met the criteria, and group A2 (7/19) who did not. Patient survivals were compared. RESULTS: In the explanted liver, CT images correlated well with pathological specimens showing that TAE induced massive tumor necrosis (>85%) in 63.1% of patients in group A and all 7 patients in group A2 exhibited tumor downgrading that met Milan criteria. The overall 5-year actuarial survival rate was 80.6%. The TAE group had a better survival (84% at 5 years) than the non-TAE (75% at 4 years). The 3-year survival of group A2 (83%) was also higher than that of group A1(79%). Tumor necrosis >85% was associated with excellent survival of 100% at 3 years, which was significantly better than the others who showed <85% tumor necrosis (57.1% at 3 years) or who did not have TAE (75% at 3 years). CONCLUSION: TAE is an effective treatment for HCC before LT. Excellent long-term survival was achieved in patients that did not fit Milan criteria. Our results broadened and redefined the selection policy for LT among patients with HCC. Meticulous pre-LT TAE helps in further reducing the rate of dropout from waiting lists and should be considered for patients with advanced HCC.     

Outcome of transarterial chemoembolization in patients with inoperable hepatocellular carcinoma eligible for radiofrequency ablation

AIM: To evaluate the outcome of transarterial chemoembolization (TACE) in patients with unresectable hepatocellular carcinoma (HCC)<5 cm in diameter eligible for radiofrequency ablation (RFA). METHODS: The treatment-related mortality, morbidity, long-term survival, and prognostic factors of HCC patients who had TACE and fulfilled the present inclusion criteria for RFA were evaluated. RESULTS: Of the 748 patients treated with TACE between January 1990 and December 2002,114 patients were also eligible for RFA. The treatment-related mortality and morbidity were 1% and 19%, respectively. Survival at 1, 3, and 5 years was 80%, 43%, and 23%, respectively. Older age and a high albumin level were associated with a better survival, whereas a high a-fetoprotein level (AFP) and the size of the largest tumor >3 cm in diameter were adverse prognostic factors in multivariate analysis. CONCLUSION: The morbidity, mortality, and survival data after TACE for small HCCs eligible for RFA are comparable to those reported after RFA in the literature. Our data suggest the need for a randomized comparison of the two treatment modalities for small HCCs.     

Idarubicin vs doxorubicin in transarterial chemoembolization of intermediate stage hepatocellular carcinoma

BACKGROUND Liver cancer is the fifth most common cancer and the second cause of cancerrelated deaths worldwide.Transarterial chemoembolization(TACE)is the best treatment of intermediate hepatocellular carcinoma(HCC).Doxorubicin is the most commonly used drug despite a low level of evidence.AIM To compare the objective response rate of idarubicin-based TACE(Ida-TACE)against doxorubicin-based TACE(Dox-TACE)in intermediate stage HCC.METHODS Between January 2012 and December 2014,all patients treated with TACE at our academic hospital were screened.Inclusion criteria were patients with Child-Pugh score A or B,a performance status below or equal to 1,and no prior TACE.Either lipiodol TACE or drug-eluting beads TACE could be performed with 10 mg of idarubicin or 50 mg of doxorubicin.Each patient treated with idarubicin was matched with two doxorubicin-treated patients.The TACE response was assessed by independent radiologists according to the mRECIST criteria.RESULTS Sixty patients were treated with doxorubicin and thirty with idarubicin.There were 93%and 87%of cirrhotic patients and 87%and 70%of Child-Pugh A in the doxorubicin and idarubicin groups,respectively.The median number of HCC per patient was two in both groups with 31%and 26%of single nodules in doxorubicin and idarubicin groups,respectively.Objective response rate after first TACE was 76.7%and 73.3%(P=0.797)with 41.7%and 40.0%complete response in doxorubicin and idarubicin groups,respectively.Progression-free survival was 7.7 mo in both groups,and liver transplant-free survival was 24.9 mo and 21.9 mo in doxorubicin and idarubicin groups,respectively.Safety profiles were similar in both groups,with grade 3-4 adverse events in 35%of Dox-TACE and 43%of Ida-TACEs.CONCLUSION Ida-TACE and Dox-TACE showed comparable results in terms of efficacy and safety.Ida-TACE may represent an interesting alternative to Dox-TACE in the management of patients with intermediate stage HCC.     

Outcome of transarterial chemoembolization-based multi-modal treatment in patients with unresectable hepatocellular carcinoma

AIM:To investigate the efficacy and safety of transarterial chemoembolization(TACE)-based multimodal treatment in patients with large hepatocellular carcinoma(HCC).METHODS:A total of 146 consecutive patients were included in the analysis,and their medical records and radiological data were reviewed retrospectively.RESULTS:In total,119 patients received TACE-based multi-modal treatments,and the remaining 27 received conservative management.Overall survival(P<0.001)and objective tumor response(P=0.003)were significantly better in the treatment group than in the conservative group.After subgroup analysis,survival benefits were observed not only in the multi-modal treatment group compared with the TACE-only group(P=0.002)but also in the surgical treatment group compared with the loco-regional treatment-only group(P<0.001).Multivariate analysis identified tumor stage(P<0.001)and tumor type(P=0.009)as two independent pre-treatment factors for survival.After adjusting for significant pre-treatment prognostic factors,objective response(P<0.001),surgical treatment(P=0.009),and multi-modal treatment(P=0.002)were identified as independent post-treatment prognostic factors.CONCLUSION:TACE-based multi-modal treatments were safe and more beneficial than conservative management.Salvage surgery after successful downstaging resultedin long-term survival in patients with large,unresectable HCC.     

A prediction model for liver abscess developing after transarterial chemoembolization in patients with hepatocellular carcinoma

BackgroundLiver abscess is a rare but potentially fatal complication of transarterial chemoembolization. Other than for biliary abnormalities, risk factors for liver abscess formation after transarterial chemoembolization have rarely been discussed.AimsTo identify other risk factors of liver abscess after transarterial chemoembolization in patients with hepatocellular carcinoma.MethodsData for 5299 patients with hepatocellular carcinoma who underwent transarterial chemoembolization from July 1999 to December 2009 were retrospectively reviewed. 72 patients who experienced liver abscess after transarterial chemoembolization were enrolled as a case group, which was compared with a randomly selected control group (n = 1009) of patients who did not develop liver abscess after transarterial chemoembolization.ResultsPneumobilia, type 2 biliary abnormality, type 1 biliary abnormality, diabetes mellitus, tumour number (≥3), tumour size (≥3 cm), and tumour necrosis on the pre-transarterial chemoembolization computed tomography, and gelfoam embolization and vessel injury during transarterial chemoembolization were all significant predisposing factors for liver abscess after transarterial chemoembolization. A prediction model for postembolization liver abscess was developed from these risk factors.ConclusionThe group of patients with risk scores greater than 71 showed a significantly increased risk of liver abscess after transarterial chemoembolization. These high-risk patients should be monitored carefully after transarterial chemoembolization.     

原发性肝癌的非手术治疗

原发性肝癌（下简称肝癌）主要是肝细胞癌，少数是胆管细胞癌。我国是肝癌高发地区，其恶性程度高，进展快，治疗棘手，预后差。外科手术切除或肝移植是最有效的治疗，但绝大多数病例属于中晚期或有严重的肝硬化，而不适合外科手术治疗^[1]，因而非手术治疗适用于大多数病例或与外科手术相结合提高治疗效果^[1,2]。     

Sequential use of transarterial chemoembolization and percutaneous cryosurgery for hepatocellular carcinoma

AIM： To evaluate the efficacy of sequential use of transarterial chemoembolization （TACE） and percutaneous cryosurgery for unresectable hepatocellular carcinoma （HCC）. METHODS： Four hundred and twenty patients were enrolled in this study. The patients, who were considered to have unresectable tumors due to their location or size or comorbidity, were divided into sequential TACE-cryosurgery （sequential） group （n = 290） and cryosurgery alone （cryoalone） group （n = 130）. Patients in the sequential group tended to have larger tumors and a greater number of tumors than those in the cryo-alone group. Tumors larger than 10 cm in diameter were only seen in the sequential group. TACE was performed with the routine technique and percutaneous cryosurgery was conducted under the guidance of ultrasound 2-4 wk after TACE. RESULTS： During a mean follow-up period of 42 ± 17 mo （range, 24-70 mo）, the local recurrence rate at the ablated area was 17% for all patients, 11% and 23% for patients in sequential group and cryoalone groups, respectively （P = 0.001）. The overall 1-, 2-, 3-, 4- and 5-year survival rate was 72%, 57%, 47%, 39% and 31%, respectively. The 1- and 2-year survival rates （71% and 61%） in sequential group were similar to those （73% and 54%） in cryo-alone group （P = 0.69 and 0.147）, while the 4- and 5-year survival rates were 49% and 39% in sequential group, higher than those （29% and 23%） in cryo-alone group （P = 0.001）. Eighteen patients with large HCC （〉 5 cm in diameter） survived for more than 5 years after sequential TACE while no patient with large HCC （〉 5 cm in diameter） survived more than 5 years after cryosurgery. The overall complication rate was 24%, and the complication rates were 21% and 26% for the sequential and cryo-alone groups, respectively （P = 0.06）. The incidence of hepatic bleeding was higher in cryo-alone group than in sequential group （P = 0.02）. Liver crack only occurred in two patients of the cryoalone group. CONCLUSION： Pre-cryosurgical TACE can increase the cryoablation efficacy and decrease its adverse effects, especially bleeding. Sequential TACE and cryosurgery may be the better procedure for unresectable HCC, especially for large HCC.     

经肝动脉化疗栓塞后联合索拉非尼治疗肝癌患者临床观察

目的探讨索拉非尼联合经肝动脉化疗栓塞术（TACE）治疗肝癌患者的效果。方法选取142例肝癌患者,其中57例接受TACE治疗,47例接受索拉非尼治疗,38例接受索拉非尼联合TACE治疗。在治疗后12 w,评估治疗效果、总生存期（OS）和疾病进展时间（TTP）。结果联合治疗组有效率为26.32%,显著高于TACE组的17.54%或索拉非尼组的19.15%（P<0.05）;联合治疗组疾病控制率为71.05%,显著高于TACE组的57.89%或索拉非尼组的53.19%（P<0.01）;联合治疗组患者OS为8.6 m,显著高于索拉非尼组的6.2 m或TACE组的7.3 m（P<0.05）;联合治疗组TTP为6.7 m,显著高于索拉非尼组的5.1m或TACE组的 5.6 m（P<0.01）。结论索拉非尼联合TACE治疗肝癌患者具有较好的临床效果。     

Analysis of aggressiveness factors in hepatocellular carcinoma patients undergoing transarterial chemoembolization

AIM To investigate novel predictors of survival in hepatocellular carcinoma(HCC) patients following transarterial chemoembolization(TACE).METHODS One hundred sixty seven patients with un-resectable HCC were retrospectively analyzed to identify factors that might contribute to their HCC biology and aggressiveness. We correlated routine laboratory results(total bilirubin, AST, ALKP, GGTP, albumin etc.) to maximum tumor diameter, number of tumor nodules, portal vein thrombosis and blood alpha-fetoprotein levels. These 4 parameters were previously combined to form an aggressiveness index(AgI). We used The Wilcoxon ranksum(Mann-Whitney), to test the correlation between the AgI categories and liver function parameters. The Cox proportional hazards model was applied to evaluate the categories of AgI associated with overall survival. RESULTS The AgI was strongly correlated with survival in this novel patient population. Three year survival probability for AgI or 4 was 42.4% vs 61.8%; P 0.0863 respectively. Several factors independently correlated with AgI using univariate multiple logistic regression of AgI with 8 laboratory parameters. Lower albumin levels had an OR of 2.56(95%CI: 1.120-5.863 P 0.026), elevated Alkaline phosphatase and gamma glutamyl transpeptidase(GGTP) had ORs of 1.01(95%CI: 1.003-1.026, P 0.017) and 0.99(95%CI: 0.99-1.00, P 0.053) respectively. In a Cox proportional hazard model combining mortality for AgI score and liver function parameters, only GGTP levels and the AgI were independently associated with survival. An AgI 4 had HR for mortality of 2.18(95%CI: 1.108-4.310, P 0.024). GGTP's single unit change had a HR for mortality of 1.003(95%CI: 1.001-1.006, P 0.016). These were considered in the final multivariate model with the total cohort. An AgI 4 had a HR for mortality of 2.26(95%CI: 1.184-4.327, P 0.016). GGTP had a HR of 1.003(95%CI: 1.001-1.004, P 0.001).CONCLUSION Our study validates the AgI in a new population with un-resectable HCC patients undergoing TACE. The analysis establishes a correlation between GGTP and the AgI.