The ART strategy: Sequential assessment of the ART score predicts outcome of patients with hepatocellular carcinoma re-treated with TACE
Authors: F. Yousuf, T.J.S. Cross, D. Palmer
Journal: Journal of Hepatology (2014)

The ART-strategy: Sequential assessment of the ART score predicts outcome of patients with hepatocellular carcinoma re-treated with TACEJournal of HepatologyVol. 60Issue 1PreviewRecently, we developed the ART score (assessment for re-treatment with TACE) to guide the decision for a second transarterial chemoembolization (TACE-2) in patients with hepatocellular carcinoma (HCC). Patients with an ART score of 0–1.5 points gained benefit from a second TACE session, while patients with an ART score ⩾2.5 points did not. Here, we investigated (1) the prognostic significance of the ART score prior to the third (TACE-3) and fourth TACE (TACE-4), and (2) the feasibility of an ART score guided re-treatment strategy by sequential assessment of the ART score in HCC patients treated with multiple TACE sessions. Full-Text PDF Reply to the Letters to the Editor regarding the sequential ART-ScoreJournal of HepatologyVol. 61Issue 1PreviewWe would like to thank Yousuf and colleagues for the thoughtful comments on our work regarding the sequential use of the ART score to select patients for retreatment with TACE [1]. They are right in commenting that the Child-Pugh score (CPS) consists of 5 variables but the reason why we use the change in CPS was that in our uni- and multivariate analysis from the original ART-score manuscript, the change in composite CPS was a better predictor for survival than the change in the individual variables included in the CPS [2]. Full-Text PDF Open Access Hucke and colleagues are to be congratulated on their work predicting likely response to multiple cycles of transarterial chemoembolization (TACE) [[1]Hucke F. Sieghart W. Pinter M. Graziadei I. Vogel W. Muller W. et al.The ART strategy: sequential assessment of the ART score predicts outcome of patients with hepatocellular carcinoma re-treated with TACE.J Hepatol. 2014; 60: 118-126Abstract Full Text Full Text PDF PubMed Scopus (96) Google Scholar]. However, there are some issues that need addressing. Firstly, the authors assert that the ART score is derived from 3 variables. This is not true. The Child-Pugh score itself consists of 5 variables thus, it actually consists of 7 variables. In addition, the greatest weighting for the ART score is not placed on evidence of radiological response but on evidence of progressive cirrhosis and worsening liver synthetic function. A rising aspartate aminotransferase (AST) is well documented in advanced disease as a marker of more severe cirrhosis [2Cross T.J.S. Rizzi P. Berry P.A. Bruce M. Portmann B. Harrison P.M. King's score: an accurate marker of cirrhosis in chronic hepatitis C.Eur J Gastroenterol Hepatol. 2008; : 1-9PubMed Google Scholar, 3Kamimoto Y. Horiuchi S. Tanase S. Morino Y. Plasma clearance of intravenously injected aspartate aminotransferase isozymes: evidence for preferential uptake by sinusoidal liver cells.Hepatology. 1985; 5: 367-375Crossref PubMed Scopus (156) Google Scholar]. It would have been useful to have seen the individual biochemical constituents of the Child-Pugh score and assessed their impact on predicting outcome. An alternative score for predicting patient outcome after TACE is available. The hepatoma arterial-embolization prognostic score (HAP) was derived to assess likely response to TACE [[4]Kadalayil L. Benini R. Pallan L. O'Beirne J. Marelli L. Yu D. et al.A simple prognostic scoring system for patients receiving transarterial embolization for hepatocellular cancer.Ann Oncol. 2013; : 1-6Google Scholar]. The score was derived from a training set of 114 patients from which the score was developed, and then validated in an independent sample of 167 patients. Patients were assigned 1 point for albumin <36 g/dl, bilirubin >17 μmol/l, AFP >400 ng/ml, or size of dominant lesion >7 cm, and has the advantage of not relying on assessment of response to previous TACE. The score was calculated by adding up their respective points. Patients were then divided into four groups: HAP score 0 = A, HAP 1 = B, HAP 2 = C, HAP >2 = D. The median survival for the respective groups was 27.6 months, 18.5 months, 9 months, and 3.6 months. Future studies in this field should compare the performance of both the ART strategy and the HAP score to determine their applicability and how they could best be used to help our patients. The authors declared that they do not have anything to disclose regarding funding or conflict of interest with respect to this manuscript.