Comment on “Development and validation of the NTAA prognostic model for BCLC stage B hepatocellular carcinoma undergoing transarterial chemoembolization”

To the Editor, Chen et al address a long-standing problem in intermediate-stage (BCLC B) hepatocellular carcinoma (HCC): outcomes after first transarterial chemoembolization (TACE) are heterogeneous, and practical tools to individualize prognosis – especially in patients with preserved liver function – remain imperfect[1,2]. This commentary was prepared in line with the TITAN 2025 guideline to promote transparent and responsible reporting[3]. A major strength is the authors’ deliberate focus on a clinically coherent population (Child–Pugh A, BCLC B) and on variables that are universally available at baseline. Their four-component NTAA score (tumor Number, tumor size T, AFP, and ALBI grade) is well aligned with the 2022 BCLC update, which emphasizes that BCLC B should be subclassified by tumor burden and liver function rather than treated as a single entity[2]. Using ALBI – an objective, reproducible liver reserve metric – also avoids some subjectivity inherent to Child–Pugh stratification and has strong prognostic grounding in HCC[4]. Methodologically, the multicenter scale and validation strategy are compelling. The authors report clear separation of overall survival across NTAA risk strata (median OS 68.1 vs 35.7 vs 15.4 months), suggesting that a “minimal-variable” model can still capture clinically meaningful biology and hepatic reserve[1]. For real-world use, this kind of parsimonious baseline tool is attractive for pre-TACE counseling and for identifying patients who may warrant earlier intensification (combination strategies, trial enrollment) rather than repeated TACE alone[2]. The key question is how NTAA should sit alongside established TACE prognostic frameworks. Classic baseline scores such as the HAP score also integrate tumor burden and liver function and have been widely used to benchmark outcomes after TACE/TAE[2]. Meanwhile, retreatment-oriented tools (e.g., ART score) explicitly incorporate early post-TACE changes to inform whether subsequent TACE is likely to benefit – an important complement because prognosis after the first session is strongly shaped by tolerance and response[5]. NTAA’s strength is its simplicity at time zero; a pragmatic next step would be to evaluate whether pairing NTAA (baseline risk) with a response-based metric (e.g., ART) yields a more actionable pathway for “continue TACE vs switch strategy” decisions[2,5]. Finally, generalizability requires careful consideration. The derivation cohort is predominantly HBV-related and China-based, where baseline AFP/ALBI distributions, imaging intervals, and subsequent systemic options may differ from HCV/NAFLD-predominant settings[1,2]. Prospective external validation with prespecified thresholds and calibration reporting across etiologies will be essential before NTAA is used to gatekeep treatment escalation.