HBV reactivation in HCC patients following TACE: risk factors, antiviral therapy impact, and survival analysis

Background Hepatitis B virus (HBV) reactivation after transcatheter Arterial Chemoembolization (TACE) can lead to severe complications and affect prognosis. Current research on HBV reactivation following TACE is limited and inconsistent. Long-term prognostic data on antiviral therapy (AVT) in patients undergoing TACE are also scarce. Purpose This study aimed to evaluate the risk factors for HBV reactivation in hepatitis B surface antigen (HBsAg) positive Hepatocellular carcinoma (HCC) patients following TACE and the impact of prophylactic AVT on HBV reactivation and survival outcomes. Patients and methods This retrospective study included HBsAg-positive, treatment-naive HCC patients who underwent TACE between December 2020 and December 2024. Patient baseline characteristics, TACE procedures, and follow-up data were collected. HBV reactivation was defined as a ≥2 log IU/mL increase in HBV DNA levels from baseline or HBsAg seroconversion. Prophylactic AVT was defined as anti-HBV drug administration before or during TACE, continued throughout follow-up. Survival outcomes were assessed using the Kaplan-Meier method, log-rank test and Cox proportional hazards regression analyses. Results A total of 168 patients were enrolled. HBV reactivation occurred in 32 patients (19.0%). Multivariate analysis identified the absence of prophylactic AVT (odds ratio [OR] 3.56, 95% CI 1.55-8.18, P = 0.003) and chemotherapeutic agents (>2 agents) (OR 2.79, 95% CI 1.09-7.14, P = 0.032) as independent risk factors for HBV reactivation. Unadjusted Kaplan–Meier analysis showed that patients without HBV reactivation had significantly better OS (P = 0.036). Multivariable Cox proportional hazards regression analysis confirmed that HBV reactivation (hazard ratio [HR]=1.43, 95%CI:0.90–2.28, P = 0.047) and macrovascular invasion (HR = 1.69, 95%CI:1.14–2.51, P = 0.017) were independent predictors of poor OS, whereas prophylactic AVT was not significantly associated with OS (HR = 0.75, 95%CI:0.50–1.14, P = 0.182). Conclusion In HBsAg-positive HCC patients undergoing TACE, the absence of prophylactic AVT and chemotherapeutic agents (>2 agents) are significant risk factors for HBV reactivation. HBV reactivation and macrovascular invasion are independent predictors of poor OS, while prophylactic AVT shows no significant association with OS. These findings provide real-world evidence for optimizing the clinical management of HBV-related HCC patients undergoing TACE.