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Ma et al. Hepatoma Res. 2026;12:43 Page 13 of 22

Dynamic prediction model: prediction based on “response”
Although the static model plays an important role in HCC treatment, its inherent “static” attribute also
brings inevitable defects. Clinicians and researchers have gradually realized that HCC treatment is a long
management process, and the prognosis of patients is not determined at the beginning of treatment but
largely depends on the effect of treatment itself and the body’s response to treatment. Dynamic prediction
models incorporate the most important dynamic variable, “treatment response”, into the core, providing
crucial decision support for the entire process management of TACE. The dynamic prediction model
dynamically adjusts the prognosis according to the patient’s response to pre-treatment to guide subsequent
treatment.

Assessment for Retreatment with TACE/Modified Assessment for Retreatment with TACE score
The Assessment for Retreatment with TACE (ART) score is the first externally validated scoring system
[49]
for TACE retreatment decisions. The construction of this system was based on the following three
independent prognostic factors: aspartate aminotransferase (AST) increase > 25% (+4 points), Child-Pugh
score increase (+1.5 points if the score increases by 1 point, +3 points if the score increases by ≥ 2 points), and
no imaging tumor response (+1 point). According to the total score, patients were divided into two groups:
0-1.5 points (median survival time was 23.7 months), and the second TACE was recommended ≥ 2.5 points
(the median survival time was 6.6 months), and the second TACE was not recommended. In a study
exploring the feasibility of sequential evaluation of the ART score in the treatment of multiple TACE , it
[50]
was proven that this score can still evaluate the prognosis and survival of patients before the third and fourth
TACE, and it is also helpful in identifying patients who may no longer benefit from multiple TACE. Since
most Chinese HCC patients have a history of HBV infection, to evaluate the prognosis of these patients after
TACE retreatment, Chen et al. constructed the Modified Assessment for Retreatment with TACE (mART)
score based on the ART score . This score includes three independent prognostic factors: elevated Child-
[51]
Pugh score (score increased by 1 point: 0.5 points; score increase is greater than or equal to 2 points: 4.5
points), BCLC stage B (2 points), and no imaging tumor response (2 points). The patients were divided into
two groups according to the mART score system, with a median survival time of 22.9 months. The survival
time in the group with a score ≥ 2.5 was 8.9 months, and there was a significant difference in the survival rate
between the two groups. The C-index of mART was 0.82, which was significantly higher than that of ART
(0.64), indicating that the mART score has a better predictive ability for Chinese patients. The ART score is a
pioneering prediction tool that establishes the core principle of “dynamic changes after treatment to guide
retreatment”. The mART score is an important localization optimization tool for this principle. It provides a
more accurate initial prognosis prediction for Chinese HCC patients by incorporating baseline staging and
adjusting the weights. However, several limitations exist: (1) The ART score heavily weights AST elevation >
25% despite limited evidence for AST/alanine aminotransferase (ALT) as independent HCC prognostic
factors; (2) Its discriminative ability declines in end-stage liver disease; patients with Child-Pugh ≥ B8 have
poor prognosis regardless of ART score after TACE-3; (3) The mART score ignores the prognostic role of
AFP and C-reactive protein (CRP); (4) It also omits HBV DNA monitoring and antiviral therapy, with no
subgroup analysis.

Previous studies combined the STATE score with the ART score and proposed a START strategy: If the
[52]
STATE score is greater than or equal to 18 points and the ART score is between 0-1.5 points, it is suitable to
continue TACE. If the STATE score is less than 18 points or the ART score is greater than or equal to 2.5
points, it is not recommended to continue TACE. The START strategy can be used to optimize patient
selection for multiple TACE treatments, systematically guide initial and re-treatment decisions of TACE, and
maximize benefits for patients.