Predictors and outcomes of hepatic decompensation following transarterial locoregional therapy in hepatocellular carcinoma

Transarterial radioembolization (TARE) and transarterial chemoembolization (TACE) are recognized locoregional therapies (LRTs) for patients with unresectable hepatocellular carcinoma (uHCC). We assessed the predictors of hepatic decompensation (HD) and its impact on overall survival (OS) in patients with uHCC undergoing TACE and TARE.We analyzed patients treated with TARE (n=135) or TACE (n=177) at four tertiary centers. HD was defined as ascites, variceal bleeding or portosystemic encephalopathy at baseline or its occurrence ≤6 months post LRT. Median OS and objective response (per mRECIST) were assessed.The cohort was predominantly male (73.9%), with a mean age of 67.1 ± 10.5 years; most had intermediate-stage (BCLC B, 54.5%), followed by early-stage (BCLC 0/A, 34.0%) and locally advanced-stage disease (BCLC C, 11.5%). HD was present at baseline in 36 patients (11.5%) and occurred after LRT in 48 patients (15.4%). The post-LRT HD group showed lower complete response rates (10.9%) than those without HD (31.4%; P = 0.002). The mOS was longer in patients without HD (41.0 months) than in those with HD at presentation (15.0 months [HR 2.35; 95% CI: 1.37-4.01) or after LRT (14.0 months [HR, 2.66; 95% CI: 1.68-4.26]). Multivariable analyses revealed hepatitis C etiology (OR 0.28, 95% CI: 0.11-0.66, P = 0.006), ALBI score (OR 2.12, 95% CI: 1.38-3.32, P = 0.001) and intervention with TARE (OR 2.20, 95% CI:1. 11-4.44, P = 0.026) as independent predictors of HD post-LRT.Post-LRT HD is common and strongly associated with reduced survival in patients with uHCC. Baseline hepatic reserve and intervention with TARE are crucial factors in predicting post-LRT HD. These findings underscore that treatment-related hepatic injury can outweigh its benefits when hepatic reserve is marginal.