Development and Validation of a Vascular Endothelial Growth Factor A-associated Prognostic Model for Unresectable Hepatocellular Carcinoma

Figures & data

Table 1 Baseline Demographics and Clinical Characteristics in All-Patient

Characteristic	All-Patient (n=182)	TACE Alone (n=83)	TACE-Sorafenib (n=99)	p value
Gender				0.312
Male	143 (78.6)	68 (81.9)	75 (75.8)
Female	39 (21.4)	15 (18.1)	24 (24.2)
Age (y)	54.48±11.41	54.92±12.10	54.12±10.85	0.641
ECOG PS				0.862
0	157 (86.3)	72 (86.7)	85 (85.9)
1	25 (13.7)	11 (13.3)	14 (14.1)
Etiologic cause				0.539
Hepatitis B	137 (75.3)	65 (78.3)	72 (72.7)
Hepatitis C	7 (3.8)	2 (2.4)	5 (5.1)
Other	38 (20.9)	16 (19.3)	22 (22.2)
Child-Pugh score				0.074
5	145 (79.7)	60 (72.3)	85 (85.9)
6	30 (16.5)	19 (22.9)	11 (11.1)
7	7 (3.8)	4 (4.8)	3 (3.0)
BCLC stage				0.828
A	35 (19.2)	17 (20.5)	18 (18.2)
B	77 (42.3)	36 (43.4)	41 (41.4)
C	70 (38.5)	30 (36.1)	40 (40.4)
Tumor size (cm)				0.690
≤5 cm	50(27.5)	24 (28.9)	26 (26.3)
>5 cm	132 (72.5)	59 (71.1)	73 (73.7)
No. of tumors				0.899
1	59	26 (31.3)	33 (33.3)
2–3	20	10 (12.0)	10 (10.1)
≥4	103	47 (56.6)	56 (56.6)
PVTT				0.726
No	127 (69.8)	59 (71.1)	68 (68.7)
Yes	55 (30.2)	24 (28.9)	31 (31.3)
EHS				0.202
No	146 (80.2)	70 (84.3)	76 (76.8)
Yes	36 (19.8)	13 (15.7)	23 (23.2)
Ascites				0.693
No	164 (90.1)	74 (89.2)	90 (90.9)
Yes	18 (9.9)	9 (10.8)	9 (9.1)
AFP (ng/mL)				0.799
≤400	99 (54.4)	46 (55.4)	53 (53.5)
>400	83 (45.6)	37 (44.6)	46 (46.6)
Total bilirubin (μmol/L)	17.5 (13.6–23.9)	18.2 (13.7–25.9)	16.4 (13.5–22.2)	0.154
ALP (U/L)	123 (89–183)	136 (89–200)	117 (89–154)	0.151
AST (U/L)	50 (31–75)	50 (31–80)	48 (30–72)	0.623
ALT (U/L)	41 (26–64)	42 (25–69)	40 (27–60)	0.586
NLR	2.95 (1.99–4.44)	3.00 (2.01–4.12)	2.81 (1.97–4.85)	0.545
VEGF (pg/mL)	154.11 (112.70–221.68)	155.77 (120.83–232.21)	148.45 (103.36–220.27)	0.376

Abbreviations: ECOG PS, Eastern Cooperative Oncology Group performance status; PVTT, portal vein tumor thrombus; EHS, extrahepatic spread; AFP, alpha-fetoprotein; ALP, alkaline phosphatase; AST, aspartate aminotransferase; ALT, alanine aminotransferase; NLR, neutrophil-lymphocyte ratio; VEGF, vascular endothelial growth factor.

Figure 1 The flowchart of the study.

Table 2 Identification of Prognostic Factors for OS in All-Patient, the TACE Group, and the TACE-Sorafenib Group Based on Univariate Cox Regression

Baseline Factor	All-Patient		TACE Group		TACE-Sorafenib Group
	HR (95% CI)	p value	HR (95% CI)	p value	HR (95% CI)	p value
Treatment (T+S vs T)	0.53 (0.35–0.79)	0.002	—	—	—	—
Age (> vs ≤60)	0.74 (0.47–1.17)	0.198	0.75 (0.41–1.37)	0.347	0.64 (0.33–1.27)	0.203
Child-Pugh stage (B vs A)	1.71 (0.69–4.22)	0.247	0.82 (0.20–3.40)	0.789	3.74 (1.13–12.40)	0.031
Tumor size (> vs ≤5cm)	1.83 (1.12–3.01)	0.017	3.04 (1.46–6.32)	0.003	1.25 (0.63–2.46)	0.528
No. of tumors
2–3 vs.1	0.98 (0.41–2.30)	0.955	1.93 (0.69–5.44)	0.211	0.25 (0.03–1.89)	0.177
≥ 4 vs.1	2.65 (1.61–4.37)	<0.001	4.05 (1.88–8.72)	<0.001	2.03 (1.04–3.98)	0.038
PVTT (Yes vs No)	3.50 (2.29–5.34)	<0.001	5.33 (2.73–10.42)	<0.001	3.31 (1.83–5.99)	<0.001
EHS (Yes vs No)	3.70 (2.38–5.74)	<0.001	7.29 (3.49–15.21)	<0.001	3.70 (2.03–6.77)	<0.001
AFP (> vs ≤400ng/mL)	2.30 (1.52–3.49)	<0.001	2.44 (1.35–4.42)	0.003	2.62 (1.43–4.80)	0.002
Tbil (> vs ≤17.5μmol/L)	1.50 (0.99–2.27)	0.053	0.84 (0.47–1.48)	0.540	2.34 (1.29–4.25)	0.005
ALP (> vs ≤122.5U/L)	2.22 (1.46–3.38)	<0.001	1.84 (1.02–3.30)	0.042	2.50 (1.37–4.55)	0.003
NLR (> vs ≤2.94)	1.82 (1.20–2.76)	0.005	1.96 (1.09–3.52)	0.025	1.82 (1.01–3.31)	0.049
VEGF (> vs ≤172.48pg/mL)	2.80 (1.84–4.26)	<0.001	3.20 (1.77–5.81)	<0.001	2.50 (1.37–4.56)	0.002

Abbreviations: T+S, TACE plus sorafenib; PVTT, portal vein tumor thrombus; EHS, extrahepatic spread; AFP, alpha-fetoprotein; Tbil, total bilirubin; ALP, alkaline phosphatase; NLR, neutrophil-lymphocyte ratio; VEGF, vascular endothelial growth factor.

Table 3 Identification of Independent Prognostic Factors for OS in All-Patient, the TACE Group, and the TACE-Sorafenib Group Based on Multivariate Cox Regression

Baseline Factor	All-Patient		TACE Group		TACE-Sorafenib Group
	HR (95% CI)	p value	HR (95% CI)	p value	HR (95% CI)	p value
Treatment (T+S vs T)	0.30 (0.19–0.47)	<0.001	—	—	—	—
No. of tumors	—	—	—	—	—	—
2–3 vs.1	0.97 (0.39–2.41)	0.948	2.35 (0.81–6.83)	0.116	—	—
≥ 4 vs.1	2.32 (1.35–3.98)	0.002	3.09 (1.38–6.89)	0.006	—	—
PVTT (Yes vs No)	2.07 (1.18–3.65)	0.012	3.56 (1.49–8.53)	0.004	—	—
EHS (Yes vs No)	2.49 (1.43–4.34)	0.001	3.65 (1.56–8.59)	0.003	2.42 (1.27–4.58)	0.007
AFP (> vs ≤400ng/mL)	1.78 (1.12–2.82)	0.014	—	—	2.85 (1.50–5.43)	0.001
Tbil (> vs ≤17.5μmol/L)	—	—	—	—	2.03 (1.07–3.86)	0.031
ALP (> vs ≤122.5U/L)	1.81 (1.15–2.86)	0.011	—	—	2.46 (1.31–4.64)	0.005
VEGF (> vs ≤172.48pg/mL)	1.95 (1.26–3.02)	0.003	2.21 (1.19–4.13)	0.013	1.92 (1.02–3.61)	0.044

Abbreviations: T+S, TACE plus sorafenib; PVTT, portal vein tumor thrombus; EHS, extrahepatic spread; AFP, alpha-fetoprotein; Tbil, total bilirubin; ALP, alkaline phosphatase; VEGF, vascular endothelial growth factor.

Figure 2 Kaplan–Meier curves for OS and PFS in HCC patients with high and low baseline serum VEGF. OS curves in (A) all-patient, (B) the TACE group, and (C) the TACE-Sorafenib group. PFS curves in (D) all-patient, (E) the TACE-Sorafenib group, and (F) the TACE group.

Figure 3 The association between VEGF, ALP, NLR, and relative hazard and variable screening by Lasso. The restricted cubic splines of (A)VEGF, (B) ALP, and (C) NLR in all-patient. (D) and (E) LASSO regression analysis identified variables screened into the VEGF-associated model.

Table 4 Variables Included in the Final Model After LASSO Regression Analysis

Characteristics	Coefficient	HR	95% CI	p value
Treatment
T+S vs T	−1.22783	0.30	0.19–0.46	<0.001
No. of tumors
2–3 and ≥4 vs.1	0.51551	1.67	1.26–2.22	<0.001
PVTT
Yes vs No	0.70540	2.02	1.15–3.56	0.014
EHS
Yes vs No	0.89631	2.45	1.41–4.26	0.001
AFP
> vs ≤400ng/mL	0.54318	1.72	1.10–2.70	0.018
ALP
> vs ≤122.5U/L	0.49200	1.64	1.04–2.57	0.032
NLR	0.12746	1.14	1.03–1.26	0.014
VEGF
> vs.≤172.48 pg/mL	0.75084	2.12	1.35–3.32	0.001
The statistic of the prognostic model
Likelihood ratio test				<0.001
Wald test				<0.001
Score (log-rank) test				<0.001

Abbreviations: T+S, TACE plus sorafenib; T, TACE; PVTT, portal vein tumor thrombus; EHS, extrahepatic spread; AFP, alpha-fetoprotein; Tbil, total bilirubin; ALP, alkaline phosphatase; NLR, neutrophil-lymphocyte ratio; VEGF, vascular endothelial growth factor.

Figure 4 The prognostic nomogram constructed from all-patient to predict OS of unresectable HCC patients. The sum of the points corresponding to each variable (total points) was used to predict the likelihood of an individual patient’s 6-month, 1-year, or 2-year survival.

Figure 5 The performance of the final model for predicting OS. The calibration curve of the model for predicting (A) 6-month, (B)1-year, and (C) 2-year OS. (D) the time-independent ROC curve of the model for predicting 6-month, 1-year, and 2-year OS.

Table 5 Comparison of the Predictive Power Between the Different Model

	6-Month	1-Year	2-Year
AUC, n (95% CI)
Final model	0.861 (0.794–0.928)	0.882 (0.824–0.939)	0.862 (0.751–0.974)
CNLC stage	0.850 (0.783–0.910)	0.857 (0.791–0.923)	0.826 (0.726–0.926)
AJCC stage	0.842 (0.768–0.916)	0.830 (0.762–0.899)	0.799 (0.692–0.905)
BCLC stage	0.839 (0.763–0.914)	0.834 (0.767–0.902)	0.797 (0.689–0.905)
Model without VEGF	0.848 (0.773–0.923)	0.856 (0.790–0.921)	0.839 (0.734–0.943)
Overall C-index
Final model	0.8083
CNLC stage	0.7900
AJCC stage	0.7759
BCLC stage	0.7761
Model without VEGF	0.7892
IDI, n (95% CI), p value
Vs CNLC stage	0.023 (−0.055 0.102)	0.036 (−0.011–0.087)	0.067 (−0.018 0.139)
	p=0.465	p=0.199	p=0.093
Vs AJCC stage	0.042 (−0.024 0.110)	0.070 (0.004–0.124)	0.090 (0.012–0.169)
	p=0.193	p=0.040	p=0.013
Vs BCLC stage	0.037 (−0.023–0.107)	0.065 (0.007–0.116)	0.091 (0.008–0.166)
	p=0.286	p=0.027	p=0.033
Vs Model without VEGF	0.015(−0.029–0.060)	0.028(−0.013–0.071)	0.039(−0.015–0.096)
	p=0.512	p=0.252	p=0.113
Continuous NRI, n (95% CI), p value
Vs CNLC stage	0.146 (−0.116–0.393)	0.185 (0.010–0.373)	0.333 (0.079–0.545)
	p=0.279	p=0.033	p=0.027
Vs AJCC stage	0.188 (−0.074 0.458)	0.321 (0.066–0.510)	0.476 (0.154–0.646)
	p=0.199	p<0.001	p=0.007
Vs BCLC stage	0.162 (−0.069–0.454)	0.306 (0.075–0.469)	0.486 (0.059–0.654)
	p=0.179	p=0.007	p=0.020
Vs Model without VEGF	0.298 (0.042–0.470)	0.339(0.017–0.489)	0.390 (0.049–0.574)
	p=0.033	p=0.040	p=0.027
AUDC
Final model	0.052	0.211	0.331
CNLC stage	0.044	0.194	0.302
AJCC stage	0.042	0.174	0.291
BCLC stage	0.043	0.178	0.291
Model without VEGF	0.047	0.197	0.312

Abbreviations: AUC, area under the curve; VEGF, vascular endothelial growth factor; IDI, integrated discrimination improvement; NRI, net reclassification index; AUDC, area under the decision curve.

Figure 6 The time-independent ROC curves of other models for predicting 6-month, 1-year, and 2-year OS and decision curve analysis (DCA). The time-independent ROC curves of (A) CNLC stage, (B) AJCC stage, (C) BCLC stage, and (D) the model without “VEGF”. The DCA of the five models for predicting (E) 6-month, (F)1-year, and (G) 2-year OS.

Figure 7 Kaplan–Meier curves of the final model stratification. (A) OS of all patients was stratified by the model stratification. (B) PFS of all patients was stratified by the model stratification. OS of patients with (C) age ≤55 and (D) age >55 was stratified by the model stratification. PFS of patients with (E) age ≤55 and (F) age >55 was stratified by the model stratification.