Application of the AAPS (AFP-ALBI-PIVKA-II-Serum Albumin) Scoring System in Efficacy Monitoring of Hepatocellular Carcinoma Treated with PD-1 Inhibitor Combined with Transcatheter Arterial Chemoembolization (TACE).

PURPOSE: Hepatocellular carcinoma (HCC) lacks reliable serological biomarkers for monitoring programmed death-1 (PD-1) inhibitor plus transcatheter arterial chemoembolization (TACE). We aimed to validate the prognostic value of alpha-fetoprotein (AFP) and protein induced by vitamin K absence or antagonist-II (PIVKA-II) reductions and establish a practical combined model (AAPS: AFP-ALBI-PIVKA-II-serum albumin). PATIENTS AND METHODS: We retrospectively analyzed 139 HCC patients treated with PD-1 inhibitor plus TACE. Patients were stratified by ≥50% vs <50% reductions in AFP and PIVKA-II. Survival was assessed by Kaplan-Meier with Log rank tests; prognostic factors by multivariate Cox regression. The AAPS score incorporated AFP reduction, PIVKA-II reduction, albumin-bilirubin (ALBI) grade, and serum albumin. X-tile identified optimal cutoffs: AFP 34%, PIVKA-II 73%, and AAPS 5 points, defining low-risk (5-8) and high-risk (0-4) groups. Model performance was evaluated by C-index, bootstrap-corrected area under the curve (AUC), calibration, and decision curve analysis (DCA). All tests were two-tailed, P < 0.05 considered significant. RESULTS: Patients with ≥50% biomarker reduction achieved higher objective response rate (ORR) and longer progression-free survival (PFS: AFP, 13.17 vs 10.72 months, P=0.009; PIVKA-II, 13.11 vs 10.87 months, P=0.012) and overall survival (OS: AFP, 14.50 vs 13.40 months; PIVKA-II, 14.60 vs 13.32 months). Multivariate analysis confirmed AFP and PIVKA-II reduction, and albumin as independent prognostic factors. ALBI grade, as an aestablished prognostic indicators in HCC, was included in the AAPS model based on its clinical relevance.The AAPS model demonstrated improved predictive accuracy for ORR, PFS, and OS versus single biomarkers. CONCLUSION: AFP/PIVKA-II reductions correlated with treatment response in HCC patients receiving PD-1 inhibitor plus TACE. The AAPS scoring model, integrating dynamic biomarkers with liver function, refines prognostic stratification and may guide personalized therapy. This serum-based assessment is unaffected by post-TACE inflammation or edema, complementing imaging evaluation.