Nomogram Based on Tumor Burden Score and Inflammation-Nutritional Indicators to Predict the Prognosis of Hepatocellular Carcinoma Patients Undergoing TACE Combined with Targeted and Immunotherapy

Purpose: This study aimed to develop and validate a prognostic model integrating the tumor burden score (TBS) with inflammation-nutritional indicators for patients with intermediate-to-advanced hepatocellular carcinoma (HCC). The model was designed to predict outcomes in patients undergoing triple therapy with transarterial chemoembolization (TACE), targeted therapy, and immunotherapy. Its predictive performance was subsequently assessed. Patients and Methods: The training cohort comprised 112 eligible patients treated at Ganzhou People’s Hospital between September 2021 and June 2024, while an external validation cohort included 84 patients from the First Affiliated Hospital of Gannan Medical University. Cox regression analysis identified independent prognostic factors for overall survival (OS), and a nomogram was constructed from these predictors. We assessed the model’s performance using the concordance index (C-index), time-dependent receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA). Based on the nomogram-derived risk scores, patients were stratified into low- and high-risk groups. Differences in OS between these groups were compared with Kaplan-Meier curves and the Log rank test. Results: Multivariate Cox analysis identified TBS, the prognostic nutritional index (PNI), the systemic immune-inflammation index (SII), and extrahepatic metastasis as independent predictors of OS (P < 0.05). The nomogram achieved a C-index of 0.778 (95% CI: 0.719– 0.838) in the training cohort and 0.689 (95% CI: 0.606– 0.772) in the external validation cohort. After bootstrap correction, the C-index was 0.793 (95% CI: 0.738– 0.848). This model consistently outperformed conventional clinical staging systems in both C-index and AUC values, while calibration curves and decision curve analysis affirmed its predictive accuracy and clinical utility. Kaplan-Meier analysis confirmed a significant difference in overall survival between the low- and high-risk groups. Conclusion: The nomogram incorporating TBS and inflammation-nutritional indicators exhibits acceptable prognostic performance and effectively identifies high-risk patients, providing valuable guidance for clinicians in risk stratification and individualized treatment planning. Keywords: hepatocellular carcinoma, inflammatory indicators, nomogram, prognostic nutritional index, tumor burden score