Impact of Procedural Quality on Outcomes of Transarterial Chemoembolization for Hepatocellular Carcinoma: A Multicenter Study

Introduction: Transarterial chemoembolization (TACE) is the primary treatment modality for intermediate-stage hepatocellular carcinoma (HCC). However, the lack of standardization to optimal technique leads to a wide variation in outcomes. This study aimed to evaluate the impact of procedure quality of TACE on HCC management. Methods: This multicenter retrospective cohort study included HCC patients with ≤4 tumors (maximum diameter ≤7 cm) treated with TACE monotherapy as first-line treatment between January 2009 and December 2022. Patients were classified into precision TACE and non-precision TACE groups based on adherence to predefined technical criteria encompassing angiography, catheterization, embolic agents, embolization endpoints, and assessment. The procedural quality was further stratified using a scoring system (where points were deducted for technical deficiencies). The primary outcome was objective response rate (ORR) after first TACE (first ORR) based on modified Response Evaluation Criteria in Solid Tumors. Secondary outcomes included overall ORR, progression-free survival (PFS), overall survival (OS), and safety profiles. Results: The analysis included 3,059 patients (median age, 58.00 years [IQR: 49.00–66.00]; 2,592 males [84.7%]) with 2,286 patients included in precision TACE and 773 patients included in non-precision TACE group. First ORR was 59.4% (1,359/2,286) in the precision TACE group versus 47.0% (363/773) in the non-precision TACE group (p < 0.001), with overall ORR of 70.6% (1,615/2,286) versus 59.8% (462/773) (p < 0.001). Median PFS was 14.00 months (IQR: 7.13–32.80) versus 10.80 months (IQR: 5.00–25.30) (HR = 0.787 [95% CI: 0.719–0.861], p < 0.001), and median OS was 33.63 months (IQR: 16.13–78.21) versus 26.37 months (IQR: 13.00–55.57) (HR = 0.792 [95% CI: 0.716–0.876], p < 0.001). The quality scoring system demonstrated a direct correlation between procedural quality and treatment response. Patients in precision TACE group had lower rates of hepatobiliary toxicity (elevated total bilirubin, 17.4% [398/2,286] vs. 33.8% [261/773], p < 0.001). Conclusion: Precision TACE was associated with improved outcomes and safety in HCC. The proposed scoring system correlates with treatment outcomes, suggesting its utility as a quality assessment tool for TACE procedures.