Predictors and Prognostic Analysis of Liver Abscess Formation After Transarterial Chemoembolization in Primary Liver Cancer: a retrospective nested case–control study

Background Liver abscess is a rare but serious complication after transarterial chemoembolization (TACE) for primary liver cancer. We aimed to identify predictors of liver abscess within 30 days after TACE and to evaluate its associations with tumor response and survival outcomes. Methods This study retrospectively enrolled primary liver cancer patients who underwent TACE at the First Affiliated Hospital of the University of Science and Technology of China (January 2017–April 2025). Liver abscess within 30 days post-TACE was defined as the primary outcome. A nested case–control design matched each abscess case to three controls by procedure week, age, and sex. Conditional logistic regression was used to determine independent predictors. Tumor response was assessed by mRECIST (objective response rate [ORR] and disease control rate [DCR]). Thirty-day survival and overall survival (OS) were compared between groups. Results Among 3,897 patients (7,447 procedures), 47 developed liver abscess within 30 days after TACE (1.21% per patient; 0.63% per procedure). In multivariable conditional logistic regression, higher pre-procedural white blood cell count (per 1×10^9/L increase; adjusted OR 1.201, 95% CI 1.059–1.362) and tumor diameter ≥ 5 cm (adjusted OR 3.787, 95% CI 1.486–9.653) were independent predictors. Tumor response did not differ significantly between groups (ORR 25.5% vs 17.7%, P  = 0.341; DCR 72.3% vs 79.4%, P  = 0.419). Thirty-day survival was 91.3% vs 94.2% ( P  = 0.512), and median OS was 293 vs 311 days (log-rank P  = 0.788) for abscess vs control groups, respectively. Among abscess cases, the median time from TACE to imaging diagnosis was 18 days, and subsequent anti-tumor therapy was delayed or interrupted in 38.3%. Conclusion Liver abscess after TACE is rare but clinically consequential. Pre-procedural inflammatory status and tumor burden—reflected by elevated white blood cell count and larger tumor size—are key predictors. Although no significant differences were observed in short-term tumor response or survival, liver abscess may disrupt treatment continuity, supporting intensified peri-procedural infection risk assessment and early monitoring in high-risk patients.