The strategic role of staging in the treatment of HCC

Abstract

The Consensus Panel makes the following recommendations based on the above currently available evidence.1. The primary staging should be clinical staging, which can be applied to all patients. The CLIP system should be the clincial staging system of choice, because it is generally applicable to most patients, it includes easily collected variables. Most importantly, it has been externally and prospectively validated. As a caveat, the CLIP system may not be applicable to patients with chronic hepatitis B.2. A secondary staging system for patients undergoing resection or liver transplantation is needed. The AJCC version of the modified TNM system should be used because it has been internally validated, although external and prospective validation is still lacking. Furthermore, it conforms to the TNM standard.3. Since neither of these systems is free of limitations, other factors which might be included in accessing prognosis include treatment-directed variables (according to BCLC), the etiology of the underlying liver disease, and newly discovered factors affecting tumor biology.4. All studies on HCC where it is appropriate to use staging should use one or both of these staging systems (CLIP and AJCC) to define the patient population. Medical journals considering such manuscripts for publication should insist on cohorts being classified according to these staging systems (excluding, of course, those studies looking at improving staging systems).5. Further studies on the validation of staging systems and harmonization of the different systems are urgently required.

Validation of a new prognostic staging system for hepatocellular carcinoma: The JIS score compared with the CLIP score

“…Therefore, this system is probably unsuitable for the current population of HCC patients, many of whom are diagnosed early at an asymptomatic stage of disease. Second, although most publications show that CLIP scores 0, 1, 2, and 3 patient populations are well discriminated from each other, there are no significant differences between CLIP scores 4, 5, and 6 patient populations as reported by Colombo et al 10 and Llovet et al 38 Furthermore, Llovet et al also noted that because the CLIP score provides almost every treatment option for all subgroups, it is not useful for treatment decisions. 38 In their previous study of prognostic factors in HCC, the CLIP groups stratified the patients into seven groups according to prognostic indicators-though in actuality they evaluated only six groups, because scores 5 and 6 were placed in the same group.…”

“…In other words, this system cannot identify the best prognostic subgroup that would benefit from curative and aggressive treatment. 10 Third, nearly 80% of the patient population is classified into a CLIP score of 0 to 2-as has been proved by many studies-which shows poor stratification ability. 9 The Japan Integrated Staging (JIS) system, a new system that is based on a combination of the Child-Turcotte-Pugh system and the Liver Cancer Study Group of Japan (LCSGJ)-which is also concordant with TNM classification for HCC by the International Hepato-Pancreato-Biliary Association and the International Union Against Cancer (UICC) 11 -has recently been proposed in Japan.…”

“…Second, the definition of tumor morphology in the best prognostic subgroup is too advanced, being uninodular with extension of less than 50% of the tumor. 10 As a result, the prognosis of their best prognostic subgroup is poor. In other words, this system cannot identify the best prognostic subgroup that would benefit from curative and aggressive treatment.…”

Natural history of hepatocellular carcinoma

“…Since staging scores developed thus far reflect differences in demographic features of the patients seen locally, expertise and treatment algorithms adopted in different centres, one wonders whether it is worth attempting to reach consensus on a single model for staging HCC. From a clinical point of view, it appears mandatory that prognostication of liver cancer should always incorporate treatment-dependent variables [14]. …”

Many staging systems for hepatocellular carcinoma: Evolution from Child‐Pugh, Okuda to SLiDe

“…Because therapeutic development for HCC in the future will possibly change patient prognoses, parameters that can change easily after treatment are not ideal. We thus need to establish a simple, precise, long‐term tolerable and easy to use staging system to achieve a close correlation between the actual survival and predicted survival, thereby leading to the widespread use of such a system 39–41 …”