Selecting an optimal staging system for hepatocellular carcinoma

Abstract

BACKGROUND: Selecting an appropriate staging system is crucial to predict the outcome of patients with hepatocellular carcinoma (HCC). The optimal prognostic model for HCC is under intense debate. This study investigated the prognostic ability of the 5 currently used staging systems, Barcelona Clinic Liver Cancer (BCLC), Cancer of the Liver Italian Program (CLIP), Japan Integrated Scoring (JIS) system, tumor-node-metastasis (TNM), and Tokyo score, for HCC. METHODS: Between 2002 and 2008, 1713 prospectively enrolled HCC patients were compared for their longterm survival by using the Akaike information criterion (AIC) according to the staging or scoring methods of these 5 models. RESULTS: The mean and median follow-up duration was 18 and 14 months, respectively. Among all patients, the CLIP staging system had the lowest AIC value in comparison with other systems in the Cox proportional hazards model, followed by the Tokyo score, JIS score, BCLC staging system, and TNM staging system. Patients undergoing curative treatment had a significantly better survival in comparison with patients undergoing noncurative treatment (P < .001). When the predictive accuracy of the staging systems was analyzed according to treatment strategy, the CLIP staging system had the lowest AIC value and remained the best prognostic model in patients undergoing curative (801 patients) and noncurative (912 patients) treatment. CONCLUSIONS: The CLIP staging system is the best long-term prognostic model for HCC in a cohort of patient with early to advanced stage of HCC. Its predictive accuracy is independent of the treatment strategy. Selecting an optimal staging system is helpful in improving the design of future clinical trials.

What is the best staging system for hepatocellular carcinoma in the setting of liver transplantation?

“…[30][31][32] A recent study compared the BCLC, CLIP, Tokyo, JIS, and TNM staging systems in 1713 Taiwanese patients, and the CLIP staging system was found to be the best overall for early to advanced HCC, regardless of the treatment strategy; this system was followed by the Tokyo, JIS, BCLC, and TNM systems. 33 Notably, only 46.8% of the patients in this report received curative treatment, which included resection (n ¼ 448), transplantation (n ¼ 4), and locoregional therapy (n ¼ 862).…”

Prognosis of unresectable hepatocellular carcinoma: Comparison of seven staging systems (TNM, Okuda, BCLC, CLIP, CUPI, JIS, CIS) in a Chinese cohort.

“…The CLIP system has been externally validated in Korean [11], Taiwanese [12], French [13], Japanese [29], American [14], German [15] cohorts. However, a study of 4525 patients in Japan had reached opposite conclusions that stratification ability and prognostic predictive power of the JIS score were much better than that of the CLIP score [9].…”

“…Many studies comparing staging systems in HCC have revealed different ranking of staging systems [11][12][13][14][15][16][17]. However, these studies included patients with early to advanced stages, or only early to intermediate stage, or only advance stage of HCC, whereas our studied population included patients with intermediate to advanced disease that is not amenable to radical treatment.…”

“…Other staging systems (except for CIS staging) have been compared and ranked in different studies [11][12][13][14][15][16][17] according to their prognostic value. Results were not consistent between studies.…”

Liver Transplantation for Hepatocellular Carcinoma (Hcc)

“…By tumor morphology the investigators meant percentage of parenchymal involvement (more than or less than 50%) and if these were uninodular, multinodular or extensive tumors. Several subsequent studies with large patient populations have demonstrated its prognostic usefulness, including a recent study from Taiwan that compared this system to four other models in 1713 patients with primary liver cancer (Hsu, 2010;Ueno, 2001). A downside to this system is that its tumor morphology classification is too broad for the current practices of aggressive hepatoma screening in high risk populations.…”