Predicting survival of patients with advanced hepatocellular carcinoma receiving combination targeted immunotherapy: an evaluation of volumetric imaging parameters

Application of imaging modalities in predicting and evaluating response to anti-vascular endothelial growth factor agents and immune checkpoint inhibitors in patients with hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the third leading cause of cancer death worldwide. Approximately 50% of patients with HCC are diagnosed at advanced stages, making them ineligible for curative treatments. Systemic therapy for advanced HCC has emerged as a critical approach to improving survival outcomes and remains an important field of clinical practice. Among systemic therapies, anti-vascular endothelial growth factor agents and immune checkpoint inhibitors are the first-line treatments for unresectable HCC. Although combined therapy is better than other treatments, most patients still have limited clinical benefits. Unfortunately, there are no reliable indicators to predict the efficacy of combined therapy. Imaging examination, as the crucial tool of HCC research, is expected to provide a new predictive method for therapeutic response to facilitate individualized treatment.

Integrating ultrasound and serum indicators for evaluating outcomes of targeted immunotherapy in advanced liver cancer

BACKGROUND

Hepatocellular carcinoma (HCC) is a major global contributor to cancer-related mortality, with advanced stages presenting substantial therapeutic challenges. Although targeted immunotherapy shows potential, many patients exhibit poor responses, underscoring the need for predictive tools to optimize treatment strategies. Emerging data indicate that ultrasound features (e.g., tumor stiffness) and serum biomarkers may serve as predictors of treatment outcomes. However, an integrated model for these predictors remains unavailable. This paper introduces a machine learning-based approach that combines ultrasound and serological data to forecast immunotherapy efficacy in patients with advanced HCC.

AIM

To develop a non-invasive predictive model for targeted immunotherapy in advanced HCC, incorporating both internal and external validation.

METHODS

Patients with advanced HCC who received targeted immunotherapy at two medical centers were enrolled and divided into internal training, internal validation, and external validation cohorts. Comprehensive clinical data were gathered. Initially, 13 machine learning algorithms were tested using the internal training cohort. The algorithm yielding the highest area under the curve (AUC) in the internal validation cohort was selected to construct a predictive model, termed the Target Immunotherapy Predictive Model (TIPM). TIPM performance was then compared with that of traditional tumor staging systems (tumor-node-metastasis, Barcelona Clinic Liver Cancer, China Liver Cancer, Hong Kong Liver Cancer, and C-reactive protein and alpha-fetoprotein in immunotherapy).

RESULTS

A total of 306 patients participated in the study, with 143 in the internal training cohort, 62 in the internal validation cohort, and 101 in the external validation cohort. In the internal validation cohort, the random forest model achieved the highest AUC (0.975, 95% confidence interval: 0.924-0.998). The key predictors for TIPM were tumor size, platelet count, tumor stiffness change, and white blood cell count. During external validation, TIPM outperformed conventional models, reaching an AUC of 0.899 (95% confidence interval: 0.840-0.957). Calibration curves demonstrated strong concordance with observed outcomes, while decision curve analysis confirmed TIPM’s enhanced clinical value. Additional metrics, such as the net reclassification index and integrated discrimination improvement, further supported TIPM’s superior predictive accuracy.

CONCLUSION

TIPM provides a robust tool for predicting targeted immunotherapy efficacy in advanced HCC, facilitating personalized treatment planning.