Baseline CT imaging features combined with clinical indicators predict prognosis in unresectable HCC treated with HAIC plus targeted therapy and immunotherapy.

[OBJECTIVE] To explore the prognostic value of baseline contrast-enhanced CT features imaging combined with clinical indicators in patients with unresectable hepatocellular carcinoma (uHCC) treated with hepatic arterial infusion chemotherapy plus targeted therapy and immunotherapy (HAIC-TI).

[METHODS] Patients with uHCC who received at least two cycles of HAIC-TI were retrospectively analyzed. Inclusion required pre-treatment contrast-enhanced CT and modified Response Evaluation Criteria in Solid Tumors (mRECIST) assessments after two HAIC-TI cycles. Patients were classified into progressive disease (PD) group and non-PD group (complete response [CR], partial response [PR], or stable disease [SD]) to identify predictors of early progression. Baseline predictors of early progression were identified using binary logistic regression analysis. For survival analysis, the patients were reclassified into the responder group (CR or PR) and the non-responder group (SD or PD). Overall survival (OS) was estimated using the Kaplan-Meier method and compared by log-rank test. Prognostic factors for OS were identified using Cox regression.

[RESULTS] A total of 132 patients were included in this study. The objective response rate (ORR) was 47.7% and disease control rate (DCR) was 86.4% based on mRECIST criteria. The median progression free survival (PFS) was significantly prolonged in the responder group compared to the non-responder group (29.6 months vs. 8.0 months, p < 0.001). Correspondingly, the median OS was longer in the responder group (not reached) than in the non-responder group (10.5 months) (p < 0.001). Non-peripheral washout on baseline CT was associated with a lower risk of early progression (odds ratio = 0.280, p = 0.027). Multivariate analysis identified satellite nodules (hazard ratio [HR] = 2.419, p = 0.002), prolonged prothrombin time(HR = 1.930, p = 0.009), Child-Pugh class B (HR = 2.346, p = 0.009), and unfavorable early treatment response (HR = 2.478, p < 0.001) as independent predictors of shorter OS, while more HAIC-TI cycles (HR = 0.505, p = 0.010) were associated with longer OS. Further subgroup analysis revealed that the number of HAIC sessions was not statistically significant in the responder group (p = 0.27), nor in non-responder group (p = 0.34).

[CONCLUSIONS] For patients with non-peripheral washout pattern in the delayed phase on imaging, the HAIC-TI treatment represents a feasible therapeutic strategy. It is noteworthy that early treatment responders showed significantly superior survival prognosis, whereas non-responders did not attain meaningful survival advantages despite receiving additional HAIC treatment cycles.