Transarterial chemoembolization outcomes for advanced hepatocellular carcinoma vs sorafenib and best supportive care in a sub-Saharan African cohort

doi:10.3748/wjg.v31.i46.112249

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World Journal of Gastroenterology

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1007-9327

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

Retrospective Cohort Study

World J Gastroenterol. Dec 14, 2025; 31(46): 112249
Published online Dec 14, 2025. doi: 10.3748/wjg.v31.i46.112249

Transarterial chemoembolization outcomes for advanced hepatocellular carcinoma vs sorafenib and best supportive care in a sub-Saharan African cohort

Sanju Sobnach, Karla Christina Sousa Silva, Ebtesam Abdel-Rashid Abdel-Shafy, Muhammad Emmamally, Catherine Wendy Spearman, Marc Bernon, Mark W Sonderup, Keith Venter, Inae Kim, Urda Kotze, Rajshree Segobin, Dale K Creamer, Stefano Cacciatore, Luiz Fernando Zerbini, Eduard Jonas

Sanju Sobnach, Muhammad Emmamally, Marc Bernon, Keith Venter, Inae Kim, Urda Kotze, Eduard Jonas, Department of Surgery, Faculty of Health Sciences, University of Cape Town, Cape Town 7925, Western Cape, South Africa

Karla Christina Sousa Silva, Luiz Fernando Zerbini, Cancer Genomics Group, International Centre for Genetic Engineering and Biotechnology, Cape Town 7925, Western Cape, South Africa

Ebtesam Abdel-Rashid Abdel-Shafy, Stefano Cacciatore, Bioinformatics Unit, International Centre for Genetic Engineering and Biotechnology, Cape Town 7925, Western Cape, South Africa

Catherine Wendy Spearman, Mark W Sonderup, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town 7925, Western Cape, South Africa

Rajshree Segobin, Dale K Creamer, Division of Radiology, University of Cape Town, Cape Town 7925, Western Cape, South Africa

Co-first authors: Sanju Sobnach and Karla Christina Sousa Silva.

Co-corresponding authors: Luiz Fernando Zerbini and Eduard Jonas.

Author contributions: Sobnach S and Silva KCS made equal contributions as co-first authors; Sobnach S, Cacciatore S, Zerbini LF, and Jonas E did conceptualization; Sobnach S, Emmamally M, Spearman CW, Bernon M, Sonderup MW, Venter K, Kim I, Kotze U, Segobin R, Creamer DK, and Jonas E performed methodology and data curation; Emmamally M, Venter K, Kim I, and Kotze U contributed to software; Sobnach S, Emmamally M, Venter K, Kim I, and Jonas E contributed to validation; Sobnach S, Silva KCS, Abdel-Shafy EAR, Emmamally M, Venter K, Kim I, Kotze U, Cacciatore S, and Jonas E contributed to formal analysis; Sobnach S, Silva KCS, Abdel-Shafy EAR, Emmamally M, Venter K, Kim I, Kotze U, Cacciatore S, Zerbini LF, and Jonas E contributed to investigation; Sobnach S, Emmamally M, Venter K, Kim I, and Kotze U contributed to resources; Sobnach S, Silva KCS, Abdel-Shafy EAR, Cacciatore S, and Jonas E did visualization; Zerbini LF and Jonas E did supervision and made equal contributions as co-corresponding authors; Sobnach S, Emmamally M, Venter K, Kim I, Kotze U, and Jonas E performed project administration; Sobnach S, Cacciatore S, Zerbini LF, and Jonas E acquired funding. All authors wrote the original draft preparation, reviewed and edited, and agreed to the published version of the manuscript.

Supported by International Centre for Genetic Engineering and Biotechnology; and Harry Crossley Foundation at the University of Cape Town.

Institutional review board statement: The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethic Committee of Faculty of Health Sciences at the University of Cape Town, No. IRB00001938.

Informed consent statement: The Ethics Committee granted a waiver of informed consent for the inclusion of participant data in the research database.

Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.

STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.

Data sharing statement: All data produced in the present study are available upon reasonable request to the authors.

Corresponding author: Luiz Fernando Zerbini, Director, Cancer Genomics Group, International Centre for Genetic Engineering and Biotechnology, Anzio Road, Observatory, Cape Town 7925, Western Cape, South Africa. luiz.zerbini@icgeb.org

Received: July 23, 2025
Revised: September 9, 2025
Accepted: October 31, 2025
Published online: December 14, 2025
Processing time: 140 Days and 22.8 Hours

Abstract

BACKGROUND

Sub-Saharan Africa (SSA) and Southeast Asia account for 80% of hepatocellular carcinoma (HCC) cases globally. Public healthcare systems in low- and middle-income countries often face significant economic constraints, resulting in limited treatment options. The objectives of this study were to identify factors associated with poor outcomes in patients with Barcelona Clinic Liver Cancer (BCLC) stage C and D undergoing transarterial chemoembolization (TACE) and to compare their outcomes to patients treated tyrosine kinase inhibitors (TKIs) or best supportive care (BSC) only.

AIM

To assess clinical outcomes and identify predictive factors that may facilitate the broader implementation of TACE in patients with advanced HCC within resource-constrained settings such as SSA.

METHODS

A single-center, retrospective cohort study was conducted to investigate the risk factors associated with the outcome of TACE in patients with BCLC stage C and D using univariate and multivariate regression analysis. Frequency matching was used to ensure comparable distributions of confounding factors across patients treated with TACE, TKIs, or BSC. Survival analysis was performed to compare outcomes among the matched groups.

RESULTS

Patients with BCLC stage C and D presenting with elevated gamma-glutamyl transferase levels or elevated aspartate aminotransferase levels or portal vein infiltration were identified as high-risk and demonstrated poor response to TACE treatment. In contrast, patients with BCLC stage C disease who lacked these high-risk features showed significantly longer overall survival when treated with TACE compared to those who received BSC or TKIs.

CONCLUSION

Gamma-glutamyl transferase levels, aspartate aminotransferase levels, and portal vein infiltration are critical risk factors to consider when determining treatment strategies for HCC patients in SSA. Patients without these factors can derive significant benefits from TACE as an alternative to BSC or TKIs.

Keywords: Hepatocellular carcinoma; Transarterial chemoembolization; Tyrosine kinase inhibitor; Best supportive care; Outcomes

Core Tip: Hepatocellular carcinoma is one of the most prevalent cancers on the African continent. In low-income countries, transarterial chemoembolization (TACE) is frequently offered as a life-prolonging treatment option, even for late-stage hepatocellular carcinoma patients. This single-center retrospective cohort study evaluated the outcomes of TACE in Barcelona Clinic Liver Cancer (BCLC) stage C and D patients. Furthermore, outcomes were compared in three matched cohorts’ patients with BCLC stage C and D treated with TACE, patients who received tyrosine kinase inhibitors, and patients who were treated with best supportive care. Furthermore, the overall survival of patients with BCLC stage C disease undergoing TACE was significantly better compared to tyrosine kinase inhibitors and best supportive care. Finally, portal vein tumor infiltration, high aspartate aminotransferase and gamma-glutamyl transferase levels were significant risk factors for poor outcomes.