Pre-procedural Bilirubin Level is Associated with Survival in Patients Undergoing Conventional TACE for Hepatocellular Carcinoma

To delineate the association between pre-procedural bilirubin level and survival in patients undergoing conventional ethiodized oil transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC). Following IRB approval, this single center, retrospective analysis of patients undergoing TACE for HCC reviewed medical record and imaging data to collect baseline demographic and disease information. Pre-procedural total bilirubin levels were analyzed in a multiple Cox regression model that accounted for gender, age, tumor burden (1;2-3;>3 lesions), and number of TACE procedures to test for an association with overall survival from first TACE treatment. Patients were censored at time of liver transplant or repeat TACE procedure, and cases were analyzed on a per TACE basis. A separate subset analysis was performed for patients with a bilirubin level >3mg/dl. A total of 317 TACE treatments were performed in 216 consecutive patients (167 male, age 61 ± 9 years) between 4/2007 and 6/2015. Pre-procedural total bilirubin levels for the entire cohort ranged from 0.3-9.4 mg/dl (mean 2.0 ± 1.4). After adjusting for all effects, an increased bilirubin level was significantly associated with decreased survival, with a bilirubin increase of 1 mg/dl increasing chance of death by a factor of 1.2 (hazard ratio = 1.2;p = 0.0369). Patients with a larger amount of tumor lesions had significantly decreased survival (hazard ratio = 1.9;p<0.0001). Gender, age, and number of TACE procedures were not significantly associated with survival (p = 0.32;p = 0.52;p = 0.90, respectively). The subset analysis for patients with a bilirubin level ≥3.0mg/dl included 78 patients with a mean bilirubin level of 4.2 ± 1.2mg/dl (range 3.0-9.4 mg/dl). In this subgroup, chance of death was increased 1.8 times compared to patients with a bilirubin level <3.0 mg/dl (hazard ratio 1.8;p = 0.0114). Pre-TACE total bilirubin elevation is associated with decreased survival. This effect is most pronounced in patients with pre-procedural bilirubin levels exceeding 3 mg/dl. These findings can help IR physicians counsel patients as to anticipated post-procedure outcomes.