Proposal of a new prognostic model for hepatocellular carcinoma: an analysis of 403 patients

Usefulness of a modified inflammation-based prognostic system for predicting postoperative mortality of patients undergoing surgery for primary hepatocellular carcinoma

OBJECTIVE

To assess and compare the predictive values of the hepatic Glasgow Prognostic Score (hGPS) and Cancer of the Liver Italian Program (CLIP) score in patients undergoing surgery for primary hepatocellular carcinoma (HCC).

METHODS

The hGPS was calculated as follows: patients with an elevated level of C-reactive protein (CRP) (>0.3 mg/dl) were allocated a hGPS of 1 or 2 depending on the absence or presence of hypoalbuminemia (<3.5 g/dl), and patients without an elevation of the CRP level (≤ 0.3 mg/dl) were allocated a hGPS of 0.

RESULTS

Three hundred patients were evaluated. The hGPS divided patients into three independent groups, and that a hGPS of 2 predicted a higher mortality rate (P < 0.001) than a hGPS of 0 or 1. Univariate analysis demonstrated that hGPS (0, 1/2) (P = 0.010) was one of the factors predictive of postoperative mortality, along with the CLIP score (0, 1/≥ 2) (P = 0.021). Comparative analysis using these two factors showed that the hGPS was predictively superior to the CLIP score (P = 0.033).

CONCLUSIONS

The hGPS is able to divide patients undergoing surgery for primary HCC into three independent groups, and is considered to be an important factor predictive of postoperative mortality in such patients.

Increased liver elasticity in patients with biliary obstruction

BACKGROUND

Transient elastography (with the FibroScan® apparatus) is a recently developed method for evaluating the severity of liver fibrosis by measuring liver elasticity. Liver elasticity may differ from the normal level in patients with obstructive jaundice because the retained bile may expand the liver. Because little is known about liver elasticity in patients with obstructive jaundice, we evaluated this feature in these patients.

METHODS

Between April 2007 and April 2008, 178 patients with biliary or pancreatic disease underwent transient elastography at the University of Tokyo Hospital. We excluded 77 patients because of concomitant cirrhotic liver disease, liver tumors, or a history of abdominal surgery. The remaining 101 patients were included in the study and were divided into obstructive jaundice (OJ; n = 43) and nonobstructive jaundice (NJ; n = 58) groups.

RESULTS

The basic patient characteristics did not differ significantly between the two groups, except for the causative diseases. The mean liver elasticity was significantly higher in the OJ group than in the NJ group (12.0 vs. 6.2 kPa, p < 0.01). In 24 patients from the OJ group, transient elastography was performed before and after biliary drainage; there was a marked reduction in the elasticity after the procedure in these patients (p < 0.01).

CONCLUSIONS

Liver elasticity increases in patients with biliary obstruction. This increase is reduced after biliary drainage, implying that the increased FibroScan® values before drainage are not due to liver fibrosis, but to temporarily increased elasticity.

Pretreatment serum albumin as a predictor of cancer survival: a systematic review of the epidemiological literature

Background

There are several methods of assessing nutritional status in cancer of which serum albumin is one of the most commonly used. In recent years, the role of malnutrition as a predictor of survival in cancer has received considerable attention. As a result, it is reasonable to investigate whether serum albumin has utility as a prognostic indicator of cancer survival in cancer. This review summarizes all available epidemiological literature on the association between pretreatment serum albumin levels and survival in different types of cancer.

Methods

A systematic search of the literature using the MEDLINE database (January 1995 through June 2010) to identify epidemiologic studies on the relationship between serum albumin and cancer survival. To be included in the review, a study must have: been published in English, reported on data collected in humans with any type of cancer, had serum albumin as one of the or only predicting factor, had survival as one of the outcome measures (primary or secondary) and had any of the following study designs (case-control, cohort, cross-sectional, case-series prospective, retrospective, nested case-control, ecologic, clinical trial, meta-analysis).

Results

Of the 29 studies reviewed on cancers of the gastrointestinal tract, all except three found higher serum albumin levels to be associated with better survival in multivariate analysis. Of the 10 studies reviewed on lung cancer, all excepting one found higher serum albumin levels to be associated with better survival. In 6 studies reviewed on female cancers and multiple cancers each, lower levels of serum albumin were associated with poor survival. Finally, in all 8 studies reviewed on patients with other cancer sites, lower levels of serum albumin were associated with poor survival.

Conclusions

Pretreatment serum albumin levels provide useful prognostic significance in cancer. Accordingly, serum albumin level could be used in clinical trials to better define the baseline risk in cancer patients. A critical gap for demonstrating causality, however, is the absence of clinical trials demonstrating that raising albumin levels by means of intravenous infusion or by hyperalimentation decreases the excess risk of mortality in cancer.

Staging systems for predicting survival of patients with hepatocellular carcinoma after surgery

AIM: To compare the staging systems for stratifying and predicting the prognosis of patients with hepatocellular carcinoma (HCC) after partial hepatectomy (PH).

METHODS: Clinical data about 438 HCC patients who underwent PH from January 1991 to December 2004 at our hospital were retrospectively analyzed. Tumor stage was evaluated following the Chinese tumor node metastasis (TNM) and barcelona clinic liver cancer (BCLC) staging systems, respectively. Survival curves for the HCC patients were plotted using the Kaplan-Meier method and differences were compared by the log-rank test. The accuracy of each system for predicting death of HCC patients was evaluated by calculating the area under the receiver operating characteristic curve.

RESULTS: The HCC patients were classified into stages I-III, stages I-IV and stages A-C, according to the 3 staging systems, respectively. Log-rank test showed that the cumulative survival rate was significantly different for the HCC patients at 3 Chinese system stages, TNM stages I and II, TNM stages III and IV, and 3 BCLC stages (P < 0.05). However, no significant difference was found in the HCC patients at TNM stages II and III. The accuracy of the Chinese and BCLC staging systems was higher than that of the TNM staging system for predicting the survival rate of HCC patients.

CONCLUSION: The Chinese and BCLC staging systems are better for stratifying and predicting the prognosis of HCC patients after PH than the TNM staging system.

Selecting an optimal staging system for hepatocellular carcinoma: comparison of 5 currently used prognostic models

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 long-term 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.

A new prognostic model for hepatocellular carcinoma based on total tumor volume: the Taipei Integrated Scoring System

BACKGROUND & AIMS

The currently used staging systems for hepatocellular carcinoma (HCC) are not satisfactory. The optimal prognostic model for HCC is still under intense debate. This study aimed to propose a new staging system for HCC based on total tumor volume (TTV) and to compare it with the currently used systems.

METHODS

A total of 2030 HCC patients undergoing different treatment strategies were retrospectively analyzed. TTV was defined as the sum of the volume of each tumor [(4/3)x3.14x(radius of tumor in cm)(3)]. The discriminatory ability of the TTV-based staging system and the four current systems, including the Barcelona Clinic Liver Cancer, Cancer of the Liver Italian Program (CLIP), Japan Integrated Staging system, and Tokyo system, was examined by comparing the Akaike information criterion (AIC) using the Cox proportional hazards model.

RESULTS

A higher TTV correlated well with the decreased survival in HCC patients (p<0.001). Among the 12 TTV-based staging systems, the TTV-Child-Turcotte-Pugh (CTP)-alpha-fetoprotein (AFP) combination provided the lowest AIC value. The TTV-CTP-AFP model consistently showed a better prognostic ability in comparison to the current four staging systems. In 936 HCC patients receiving curative treatment, the TTV-CTP-AFP model provided the second best predictive accuracy following the CLIP score. Alternatively, in 1094 patients undergoing non-curative treatment, the TTV-CTP-AFP model exhibited the smallest AIC value.

CONCLUSIONS

TTV may be a feasible tumoral prognostic predictor for HCC. In this single-hospital study that included patients with early to advanced cancer stages, the TTV-CTP-AFP model provides the best prognostic ability among 12 TTV-based and currently used staging systems.

Management of hepatocellular carcinoma: Report of Consensus Meeting in the 45th Annual Meeting of the Japan Society of Hepatology (2009)

Hepatocellular carcinoma (HCC) is responsible for approximately 600 000-700 000 deaths worldwide. It is highly prevalent in the Asia-Pacific region and Africa, and is increasing in Western countries. The evidence-based guideline for HCC in Japan was published in 2005 and revised in 2009. Apart from this guideline, a consensus-based practice manual proposed by the HCC expert panel of the Japan Society of Hepatology (JSH), which reflects widely accepted daily practice in Japan, was published in 2007. At the occasion of the 45th Annual meeting of the JSH in Kobe 4-5 June 2009, a consensus meeting of HCC was held. Consensus statements were createdbased on 67% agreement of 200 expert members.This article describes the up-to-date consensus statements which largely reflect the real world HCC practice in Japan. We believe readers of this article will gain the newest knowledge and deep insight on the management of HCC proposed by consensus of the HCC expert members of JSH.

Role of transarterial chemoembolization for hepatocellular carcinoma before liver transplantation with special consideration of tumor necrosis

Several authors suggest that local ablative therapies, specifically transarterial chemoembolization (TACE), may control tumor progression of hepatocellular carcinoma (HCC) in patients who are on the waiting list for liver transplantation (orthotopic liver transplantation, OLT). There is still no evidence if TACE followed by OLT is able to prevent recurrence of tumor, to prolong survival rate of the patients on the waiting list, or to improve the survival after OLT. We report 27 patients with HCC who underwent OLT. From these patients, 15 were pre-treated with TACE alone or in combination with percutaneous ethanol injection (PEI) or laser-induced thermo therapy (LITT). Mean time on the waiting list was 214 d for treated patients and 133 d for untreated patients. Comparing pre-operative imaging and histopathological staging post-transplant, we found 13 patients with tumor progression out of which five were treated with TACE. In two of the TACE patients a decrease of lesions could be achieved. In a single patient, there was no evidence of any residual tumor. Only one patient displayed tumor progression prior to OLT despite undergoing TACE. Comparison of outcome in patients undergoing TACE or having no TACE was not statistically significant (p = 0.5). In addition, our analysis showed that progression either in the total study population or in the TACE group alone is associated with a significant poorer outcome concerning overall survival (p = 0.02 and p = 0.02).

Reporting methods in studies developing prognostic models in cancer: a review

BACKGROUND

Development of prognostic models enables identification of variables that are influential in predicting patient outcome and the use of these multiple risk factors in a systematic, reproducible way according to evidence based methods. The reliability of models depends on informed use of statistical methods, in combination with prior knowledge of disease. We reviewed published articles to assess reporting and methods used to develop new prognostic models in cancer.

METHODS

We developed a systematic search string and identified articles from PubMed. Forty-seven articles were included that satisfied the following inclusion criteria: published in 2005; aiming to predict patient outcome; presenting new prognostic models in cancer with outcome time to an event and including a combination of at least two separate variables; and analysing data using multivariable analysis suitable for time to event data.

RESULTS

In 47 studies, prospective cohort or randomised controlled trial data were used for model development in only 33% (15) of studies. In 30% (14) of the studies insufficient data were available, having fewer than 10 events per variable (EPV) used in model development. EPV could not be calculated in a further 40% (19) of the studies. The coding of candidate variables was only reported in 68% (32) of the studies. Although use of continuous variables was reported in all studies, only one article reported using recommended methods of retaining all these variables as continuous without categorisation. Statistical methods for selection of variables in the multivariate modelling were often flawed. A method that is not recommended, namely, using statistical significance in univariate analysis as a pre-screening test to select variables for inclusion in the multivariate model, was applied in 48% (21) of the studies.

CONCLUSIONS

We found that published prognostic models are often characterised by both use of inappropriate methods for development of multivariable models and poor reporting. In addition, models are limited by the lack of studies based on prospective data of sufficient sample size to avoid overfitting. The use of poor methods compromises the reliability of prognostic models developed to provide objective probability estimates to complement clinical intuition of the physician and guidelines.

Reporting performance of prognostic models in cancer: a review

BACKGROUND

Appropriate choice and use of prognostic models in clinical practice require the use of good methods for both model development, and for developing prognostic indices and risk groups from the models. In order to assess reliability and generalizability for use, models need to have been validated and measures of model performance reported. We reviewed published articles to assess the methods and reporting used to develop and evaluate performance of prognostic indices and risk groups from prognostic models.

METHODS

We developed a systematic search string and identified articles from PubMed. Forty-seven articles were included that satisfied the following inclusion criteria: published in 2005; aiming to predict patient outcome; presenting new prognostic models in cancer with outcome time to an event and including a combination of at least two separate variables; and analysing data using multivariable analysis suitable for time to event data.

RESULTS

In 47 studies, Cox models were used in 94% (44), but the coefficients or hazard ratios for the variables in the final model were reported in only 72% (34). The reproducibility of the derived model was assessed in only 11% (5) of the articles. A prognostic index was developed from the model in 81% (38) of the articles, but researchers derived the prognostic index from the final prognostic model in only 34% (13) of the studies; different coefficients or variables from those in the final model were used in 50% (19) of models and the methods used were unclear in 16% (6) of the articles. Methods used to derive prognostic groups were also poor, with researchers not reporting the methods used in 39% (14 of 36) of the studies and data derived methods likely to bias estimates of differences between risk groups being used in 28% (10) of the studies. Validation of their models was reported in only 34% (16) of the studies. In 15 studies validation used data from the same population and in five studies from a different population. Including reports of validation with external data from publications up to four years following model development, external validation was attempted for only 21% (10) of models. Insufficient information was provided on the performance of models in terms of discrimination and calibration.

CONCLUSIONS

Many published prognostic models have been developed using poor methods and many with poor reporting, both of which compromise the reliability and clinical relevance of models, prognostic indices and risk groups derived from them.

The 2008 Okuda lecture: Management of hepatocellular carcinoma: from surveillance to molecular targeted therapy

Hepatocellular carcinoma (HCC) is responsible for approximately 600,000-700,000 deaths worldwide. It is highly prevalent in the Asia-Pacific region and Africa, and is increasing in Western countries. Alpha fetoprotein (AFP) alone is insufficient for HCC screening. A combination with other tumor markers, such as PIVKA-II and AFP-L3, and periodical ultrasound surveillance is necessary. Sensitivity of AFP in depicting HCC is highest, followed by PIVKA-II and AFP-L3, but the order of the specificity is inverse, AFP-L3, PIVKA-II, and AFP. Sonazoid-enhanced ultrasound (US) is extremely useful to characterize hepatic tumors equal to or more than multidetector row computed tomography (MDCT). Sonazoid-enhanced US with defect re-perfusion imaging is a breakthrough technique in the treatment of HCC. Defect re-perfusion imaging will markedly change the therapeutic strategy for liver cancer. Gd-EOB-DTPA-magnetic resonance imaging is a newly developed imaging technique in the detection and diagnosis of HCC. It is the most sensitive tool in the differentiation of early HCC from dysplastic nodules. Regarding the treatment strategy, there has been no established systemic chemotherapy for advanced HCC, except for Sorafenib. Empirically, intrahepatic arterial infusion chemotherapy using implanted reservoir port is known to be effective in response rate and overall survival for advanced HCC with vascular invasion. Sorafenib in combination with transcatheter arterial chemoembolization or adjuvant use after ablation or resection will significantly prolong the life expectancy if ongoing clinical trials provide positive results. In conclusion, it is expected that readers will gain deeper insight into the latest progress and updated diagnosis and treatment of HCC described in this review.

Tumor and liver determinants of prognosis in unresectable hepatocellular carcinoma: a large case cohort study

OBJECTIVES

967 patients with unresectable and untransplantable, biopsy-proven hepatocellular carcinoma (HCC) were prospectively evaluated at baseline and followed up till death. Survival was the end point.

RESULTS

We found that male gender, ascites, cirrhosis, portal vein thrombosis (PVT), elevated AFP or bilirubin, or alkaline phosphatase, were each statistically significant adverse prognostic factors. Patients with normal AFP survived longer than those with elevated AFP, even in the presence of PVT, large or bilobar tumors or cirrhosis. We used a bivariate analysis to separate patient sub groups based on liver function and tumor characteristics and found clear discrimination in survival between subsets; in addition both cirrhosis and presence of PVT were significant factors. We also used a purely mathematical approach to derive subgroups and a prognostic model for individual patients. Interestingly, the two approaches gave similar predictive information, which opens the possibility of a more detailed mathematical analysis in the future. The results of this large dataset show that amongst non-surgical HCC patients, there are clear subsets with longer survival.

CONCLUSION

The data supports the concept of heterogeneity of HCC. The three factors, bilirubin, AFP, and PVT predominate in prognosis.

Selecting a short-term prognostic model for hepatocellular carcinoma: comparison between the model for end-stage liver disease (MELD), MELD-sodium, and five cancer staging systems

BACKGROUND

The model for end-stage liver disease (MELD) and MELD-sodium (MELD-Na) are prognostic models for cirrhotic patients with or without hepatocellular carcinoma (HCC). This study compared the predictive accuracy between the MELD, MELD-Na, TNM (tumor, node, metastasis), Cancer of the Liver Italian Program (CLIP), Barcelona Clinic Liver Cancer (BCLC), Japan Integrated Scoring (JIS), and Tokyo score for 3-month and 6-month mortality in HCC patients.

METHODS

A total of 953 patients were prospectively enrolled. The predictive accuracy was compared between different models using the area under receiver operating characteristic curve (AUC).

RESULTS

The CLIP system had the highest AUC (0.875) for predicting 3-month mortality, followed by the Tokyo score (0.874), JIS (0.868), BCLC (0.855), MELD-Na (0.829), MELD (0.803), and finally, TNM (0.795) system. At 6 months, the top 3 models and their AUCs were the CLIP (0.882), Tokyo (0.861), and JIS (0.85). MELD-Na consistently had significantly better predictive accuracy than the MELD at 3 and 6 months. The MELD and MELD-Na were better prognostic models in predicting the mortality for surgical patients (AUC, 0.719 to 0.740), whereas the CLIP and Tokyo systems were the 2 better models in staging nonsurgical (AUC, 0.849 to 0.884) and high-risk patients (AUC, 0.790 to 0.846), defined as having at least 2 independent risk factors of mortality, at 3 and 6 months.

CONCLUSIONS

The MELD-Na may improve the prognostic ability of the MELD system for patients with HCC. Both the CLIP and Tokyo systems are better short-term prognostic models. These findings are helpful in designing future clinical trials for HCC.

Comparative performances of staging systems for early hepatocellular carcinoma

BACKGROUND

Several staging systems for patients with hepatocellular carcinoma (HCC) have been proposed, but studies of their prognostic accuracy have yielded conflicting conclusions. Stratifying patients with early HCC is of particular interest because these patients may derive the greatest benefit from intervention, yet no studies have evaluated the comparative performances of staging systems in patients with early HCC.

METHODS

A retrospective cohort study was performed using data on 379 patients who underwent liver resection or liver transplantation for HCC at six major hepatobiliary centres in the USA and Europe. The staging systems evaluated were: the Okuda staging system, the International Hepato-Pancreato-Biliary Association (IHPBA) staging system, the Cancer of the Liver Italian Programme (CLIP) score, the Barcelona Clinic Liver Cancer (BCLC) staging system, the Japanese Integrated Staging (JIS) score and the American Joint Committee on Cancer/International Union Against Cancer (AJCC/UICC) staging system, 6th edition. A recently proposed early HCC prognostic score was also evaluated. The discriminative abilities of the staging systems were evaluated using Cox proportional hazards models and the bootstrap-corrected concordance index (c).

RESULTS

Overall survival of the cohort was 74% at 3 years and 52% at 5 years, with a median survival of 62 months. Most systems demonstrated poor discriminatory ability (P > 0.05 on Cox proportional hazards analysis, c approximately 0.5). However, the AJCC/UICC system clearly stratified patients (P < 0.001, c = 0.59), albeit only into two groups. The early HCC prognostic score also clearly stratified patients (P < 0.001, c = 0.60) and identified three distinct prognostic groups.

DISCUSSION

The early HCC prognostic score is superior to the AJCC/UICC staging system (6th edition) for predicting the survival of patients with early HCC after liver resection or liver transplantation. Other major HCC staging systems perform poorly in patients with early HCC.

Treatment strategy for hepatocellular carcinoma: expanding the indications for radiofrequency ablation

BACKGROUND

Radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) is ordinarily indicated for those with three or fewer nodules, none of which exceeds 3 cm in diameter. This study investigated whether an apparent threshold exists in the diameter and number of nodules in terms of the prognosis of patients with HCC.

METHODS

We enrolled 663 naïve patients with HCC who were treated with RFA at our hospital between 1999 and 2005. We analyzed the patients' prognosis using multivariate Cox proportional regression with the diameter and number of nodules as covariates and Child-Pugh class as a stratification factor. The diameter and number were categorized as <or=2.0, 2.1-3.0, 3.1-4.0, 4.1-5.0, and >5 cm and 1, 2-3, 4-5, and >5, respectively.

RESULTS

The adjusted hazard ratio of patients whose largest nodule was <or=2.0, 2.1-3.0, 3.1-4.0, 4.1-5.0, and >5 cm was 1, 1.51, 2.56, 2.25, and 2.71, respectively. The adjusted hazard ratio of patients with one, two or three, four or five, and more than five nodules was 1, 1.35, 1.70, and 2.12, respectively. Therefore, patients with three or fewer nodules, none of which exceeds 5 cm in diameter, have a 5-year survival of 40%.

CONCLUSIONS

The prognosis of the patients worsened gradually as the diameter and number of nodules increased. No apparent threshold in the diameter or number of HCC nodules was detected. RFA can be applied beyond the conventional indications.

Nodules less than 20 mm and vascular invasion are predictors of survival in small hepatocellular carcinoma

BACKGROUND

The aims of this study were to analyze the overall survival of patients with cirrhosis and small hepatocellular carcinoma (HCC) and identify independent pretreatment predictors of survival in Brazil.

METHODS

Between 1998 and 2003, 74 patients with cirrhosis and small HCC were evaluated. Predictors of survival were identified using the Kaplan-Meier survival curves and the Cox model.

RESULTS

The overall survival rates were 80%, 41%, and 17% at 12, 36, and 60 months, respectively. The mean length of follow-up after HCC diagnosis was 23 months (median 22 mo, range: 1 to 86 mo) for the entire group. Univariate analysis showed that model for endstage liver disease (MELD) score (P=0.016), Child-Pugh classification (P=0.007), alpha-fetoprotein level (P=0.006), number of nodules (P=0.041), tumor diameter (P=0.009), and vascular invasion (P<0.0001) were significant predictors of survival. Cox regression analysis identified vascular invasion (relative risk=14.60, confidence interval 95%=3.3-64.56, P<0.001) and tumor size >20 mm (relative risk=2.14, confidence interval 95%=1.07-4.2, P=0.030) as independent predictors of decreased survival. Treatment of HCC was related to increased overall survival.

CONCLUSIONS

Identification of HCC smaller than 20 mm is associated with longer survival. Presence of vascular invasion, even in small tumors, maybe associated with poor prognosis. Treatment of small tumors of up to 20 mm diameter is related to increased survival.

Applicability of staging systems for patients with hepatocellular carcinoma is dependent on treatment method--analysis of 2010 Taiwanese patients

The aim of this study was to compare six prognostic staging systems (Okuda stage, TNM stage, CLIP score, BCLC stage, JIS score and Tokyo score) in predicting survival in patients with hepatocellular carcinoma (HCC). A total of 2010 Taiwanese HCC patients were included. Demographic, laboratory and tumour characteristics were determined at diagnosis. Predictors of survival included serum levels of albumin, total bilirubin, alkaline phosphatase, alpha-fetoprotein, ascites, tumour size and portal vein invasion. The Tokyo score was the most informative one for predicting the survival of HCC patients as a whole, receiving surgical resection, or receiving transarterial chemoembolisation. CLIP score was the best fit system for HCC patients receiving chemotherapy or supportive care. Each staging system showed a significant difference in predicting the probability of survival across different stages. The applicability of staging systems for patients with HCC was dependent on treatment methods.

Is the Cancer of the Liver Italian Program system an adequate weighting for survival of hepatocellular carcinoma? Evaluation of intrascore prognostic value among 36 subgroups

BACKGROUND

The Cancer of the Liver Italian Program (CLIP) staging system for hepatocellular carcinoma (HCC) was subdivided into 36 subgroups. We aimed to validate the prognostic value of CLIP scoring.

METHODS

This study included 3868 HCC cases treated between 1986 and 2002. Survival and prognostic impact of all subgroups were analysed.

RESULTS

In primary CLIP, comparisons of each score showed a significant difference (P<0.001) and exhibited a linear trend (P<0.001). A CLIP score of 0 was used as control group. Portal vein thrombosis, Child-Pugh B, alpha-fetoprotein (AFP) > or =400 ng/ml and multinodular with tumour extension < or =50% of the four subgroups with a CLIP score of 1 exhibited decreasing univariate hazard ratios and 95% confidence intervals, with values of 2.99 (2.05-4.37), 2.39 (2.00-2.86), 1.66 (1.40-1.96) and 1.39 (1.18-1.63) respectively. Homogeneity in the same score was evaluated by comparing subgroup survival curves. For scores 1-5, 83.3% (5/6), 57.1% (16/28), 24.4% (11/45), 3.6% (1/28) and 16.7% (1/6) pairs of survival curves significantly differed, respectively, with decreasing linear trend (P<0.001).

CONCLUSION

Different prognostic weighting of four predictive factors caused intrascore heterogeneity. Lower CLIP scores were associated with increased differences in intrascore. In conclusion, the CLIP staging scoring system is a reasonable ordinal scale, but the clinician must be aware of the heterogeneity of mortality risk within a given score.

Gain of GRHL2 is associated with early recurrence of hepatocellular carcinoma

BACKGROUND/AIMS

The aim of this study is to identify genomic changes that might be implicated in hepatocellular carcinoma (HCC) progression, and evaluate the associations with clinico-pathological features.

METHODS

The genomic DNA of 17 hepatoma cell lines was analyzed using Affymetrix GeneChip Human Mapping 50K high-density oligonucleotide arrays. We selected representative genes from recurrent amplified regions and measured the copy number of these genes in 70 HCC clinical samples.

RESULTS

We found 10 recurrent high-grade gain regions spanning less than 3 Mb in at least two hepatoma cell lines, and selected 10 representative genes. The copy number was almost normal in non-cancerous tissue and frequently amplified in Edmondson grade II or III HCC compared to Edmondson grade I HCC. Gain of TAX1BP1 in 7p15.2-1 was associated with larger tumor size and positivity of HCV antibody, and gain of CCND1 in 11q13.2-3 was associated with larger tumor size by multivariate analysis. Furthermore, a gain of GRHL2 in 8q22.3 was associated with early recurrence of HCC, controlling for clinical parameters. Decreased GRHL2 expression by RNA interference inhibits the growth of hepatoma cells, suggesting its association with cell proliferation.

CONCLUSIONS

A gain of GRHL2 might be a predictive marker for HCC recurrence.

Tumor and liver determinants of prognosis in unresectable hepatocellular carcinoma: a case cohort study

BACKGROUND AND AIMS

A total of 967 patients with unresectable and untransplantable, biopsy-proven hepatocellular carcinoma (HCC) were prospectively evaluated at baseline and followed up till death.

METHODS

Survival was the end-point for all analyses.

RESULTS

We found in our overall analysis, that male gender, ascites, cirrhosis, portal vein thrombosis (PVT), elevated alpha-fetoprotein (AFP) or bilirubin or alkaline phosphatases were each statistically significant adverse prognostic factors. Patients with normal AFP survived longer than those with elevated AFP, in the presence of PVT, large or bilobar tumors or cirrhosis. We used a bivariate analysis to separate patient subgroups based on poor liver function and aggressive tumor characteristics. In subgroup analysis based on these subsets, there was clear discrimination in survival between subsets; in addition both cirrhosis and presence of PVT were significant, independent but modest risk factors. The results of this large dataset show that amongst nonsurgical HCC patients, there are clear subsets with longer survival than other subsets.

CONCLUSIONS

This data also supports the concept of heterogeneity of HCC.

Analysis of 6381 hepatocellular carcinoma patients in southern Taiwan: prognostic features, treatment outcome, and survival

BACKGROUND

This hospital-based analysis was conducted to identify prognostic factors of hepatocellular carcinoma (HCC) in a hepatitis B virus endemic area.

METHODS

A total of 6381 HCC cases, diagnosed from 1986 to 2002, were enrolled, and 2890 (42.3%) of them were not treated. Survival rates were analyzed by correlation with the national mortality databank. Missing data and correlations among prognostic factors were considered in the analysis.

RESULTS

The overall 1-year, 3-year, 5-year, and 7-year survival rates were 44.3%, 24.9%, 17.1%, and 13%, respectively. Multivariate analysis revealed that the independent factors influencing survival were the initial treatment modality, degree of liver function impairment, hepatitis B surface antigen positivity, tumor status, and alpha-fetoprotein. Besides these well-known prognostic factors, high alanine aminotransferase (ALT) levels and a high aspartate aminotransferase (AST)/ALT ratio were identified as independent poor prognostic factors.

CONCLUSIONS

This study, which considered untreated cases, missing data, and correlations between variables and official survival data sets, provides a large-scale comprehensive survival analysis. According to our results, high ALT and high AST/ALT were independent poor prognostic factors. Therefore, viral activity should be controlled in HCC patients, and patients with elevated AST/ALT ratios should be carefully monitored.

Comparison of three current staging systems for hepatocellular carcinoma: Japan integrated staging score, new Barcelona Clinic Liver Cancer staging classification, and Tokyo score

BACKGROUND AND AIM

Although various staging systems for hepatocellular carcinoma (HCC) have been developed in recent years, there is no worldwide consensus which staging system is best. The aim of the present study was to compare the performance of the currently developed three staging systems: the Japan integrated staging (JIS) score, new Barcelona Clinic Liver Cancer (BCLC) staging classification, and the Tokyo score.

METHODS

A total of 290 consecutive patients with HCC before initial treatment at Kinki University between January 1999 and December 2001 were included. The patients were stratified according to the three staging systems, and the performance of the staging systems was compared using survival time as the only outcome measure.

RESULTS

There were significant differences between all stages in the JIS score, while no significant difference was found between stages C and D in the BCLC staging classification and between all the scores, except between scores 0 and 1 and 2 and 3 in the Tokyo score. For all patients (n = 290), the radical treatment group (n = 208) and the non-radical treatment group (n = 82), the likelihood ratio chi(2)-test showed the highest value, and the Akaike information criterion value was lowest in the JIS score.

CONCLUSION

The JIS score provided the best prognostic stratification in a Japanese cohort of HCC patients who were mainly diagnosed at early stages and treated with radical therapies.

Survival rates according to the Cancer of the Liver Italian Program scores of 345 hepatocellular carcinoma patients after multimodality treatments during a 10-year period in a retrospective study

BACKGROUND AND AIM

The Cancer of the Liver Italian Program (CLIP) score has been demonstrated to have superior prognostic ability in hepatocellular carcinoma (HCC) patients worldwide, but there has never been sufficient assessment of the efficacy of treatment modalities according to the CLIP score. This retrospective cohort study of HCC patients was conducted to assess the efficacy of treatment modalities according to the CLIP score.

METHODS

We compared the efficacy of hepatic resection (HR) (n = 101), radiofrequency ablation with prior transcatheter arterial chemoembolization (RFA + TACE) (n = 115), percutaneous ethanol injection with prior TACE (PEI + TACE) (n = 43), and TACE (n = 86) as a primary treatment in terms of survival among 345 patients treated at Mie University Hospital between 1995 and 2004, according to CLIP score.

RESULTS

The overall survival rates in the RFA + TACE group were significantly higher in the patients with CLIP scores of 1, 2, and 3 or more (5-year, 70.9%; 3-year, 73.7%; and 3-year, 100%, respectively), but they were not significantly different from the 5-year survival rates of the HR group with a CLIP score of 0 (83.7%). Among the patients with a CLIP score of 0, a significantly higher disease-free survival rate (5-year: 33.7%) was obtained in the HR subgroup (n = 35) than in the RFA + TACE subgroup (n = 35), both of which were followed since 2000, but morbidity (21.8%) was highest in the HR group.

CONCLUSION

RFA + TACE is concluded to be a safe treatment modality with better overall survival (5-year, > 60%) in HCC patients regardless of their CLIP score.

Comparison of 7 staging systems for patients with hepatocellular carcinoma undergoing transarterial chemoembolization

BACKGROUND

Many liver staging systems have been proposed for patients with hepatocellular carcinoma after locoregional therapy; however, controversies persist regarding which system is the best. In this study, the authors compared the performance of 7 staging systems in a cohort of patients with hepatocellular carcinoma who underwent transarterial chemoembolization.

METHODS

In total, 131 patients with hepatocellular carcinoma who underwent transarterial chemoembolization between August 1998 and February 2005 were included in the study. Demographic, laboratory, and tumor characteristics were determined at diagnosis and before therapy. At the time of censorship, 109 patients had died (83.2%). Predictors of survival were identified by using the Cox proportional hazards model. The likelihood-ratio chi-square statistic and the Akaike Information Criterion were calculated for 7 prognostic systems to evaluate their discriminatory ability. Comparisons of the survival rate between each stage were performed to evaluate the monotonicity of the gradients using Kaplan-Meier estimation and the log-rank test.

RESULTS

The 5-year survival rate for the entire cohort was 13.6%. The independent predictors of survival were serum albumin level (<or=3.4 g/dL), the presence of ascites, serum alpha-fetoprotein level (>60 ng/mL), and portal or hepatic vein tumor thrombosis (P= .001, P= .001, P= .004, and P= .000, respectively). The Cancer of the Liver Italian Program classification system was superior to the other 6 prognostic systems regarding discriminatory ability and the monotonicity of the gradients.

CONCLUSIONS

In this comparison of many staging systems, the Cancer of Liver Italian Program system provided the best prognostic stratification for a cohort the patients with hepatocellular carcinoma who underwent transarterial chemoembolization.

Management of hepatocellular carcinoma in Japan: consensus-based clinical practice manual proposed by the Japan Society of Hepatology

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer death not only in Japan but worldwide. Clinical Practice Guidelines for HCC were published in 2001 by the European Society of Study of the Liver (EASL) and in 2005 by the American Association for the Study of Liver Disease (AASLD). However, these guidelines have proven to be somewhat unsuitable for Japanese patients. In 2005, supported by the Japanese Ministry of Health, Labor and Welfare, Evidence-Based Clinical Practice Guidelines for HCC were compiled. Based on 'evidence-based' guidelines and the consensus of an expert panel on HCC, the Japan Society of Hepatology (JSH) published the Consensus-Based Clinical Practice Manual in 2007. In this article, the content of this manual, especially issues on surveillance, diagnosis, staging, and treatment, is summarized.

Cancer of the Liver Italian Program (CLIP) score for staging hepatocellular carcinoma

AIM

To assess the prognostic ability of the Cancer of the Liver Italian Program (CLIP) score in patients with hepatocellular carcinoma after a longer follow up.

METHODS

The updated survival data were derived from an analysis that was performed on two joined sets of data. The first set was collected retrospectively in 1995 and was used to perform an exploratory prognostic factor analysis (the CLIP-03 study), that produced the CLIP score. The second set of data was collected prospectively for the CLIP-01 randomized clinical trial.

RESULTS

Out of 912 overall patients, analysis was performed on 650 patients whose records contained all informationregarding prognostic factors. The median survival of the whole group of patients was 17.7 months and the 5-year survival rate was 10.7%. The median survival of the patients was inversely proportional to the CLIP score: the higher the CLIP score the worse the survival.

CONCLUSIONS

The CLIP score keeps good prognostic and discriminative abilities after a longer follow up and remains one the most useful prognostic system for hepatocellular carcinoma.

Review of current staging systems for hepatocellular carcinoma

Several staging systems have been developed to classify patients with hepatocellular carcinoma (HCC), however, there is no consensus on which of these is the most useful and reliable. In this review article, currently available integrated staging systems taking into account both liver function and tumor progression are presented, and their characteristics and applicability for current HCC patients, many of whom are diagnosed in the early stage of the disease and treated by curative therapy, are discussed. Based on the original andsubsequent validation studies of these staging systems, we recommend that further validation studies of staging systems for HCC should focus on the revised Barcelona Clinic Liver Cancer (BCLC) staging classification, Japan Integrated Staging (JIS) score and Tokyo score.

The model for end-stage liver disease based cancer staging systems are better prognostic models for hepatocellular carcinoma: a prospective sequential survey

OBJECTIVE

Liver cirrhosis is a major component in staging for hepatocellular carcinoma (HCC). The model for end-stage liver disease (MELD) is a better prognostic predictor for cirrhotic patients compared to the Child-Turcotte-Pugh (CTP) system, which is a parameter in Cancer of Liver Italian Program (CLIP), Barcelona Clinic Liver Cancer (BCLC), and Japan Integrated Scoring (JIS) system.

AIM

To investigate if the MELD-based models have a better prognostic ability.

METHODS

In the MELD-based model, the CTP class was replaced with MELD score at cutoffs of <10, 10-14, and >14. The modified systems were prospectively compared with the original counterpart in 430 consecutive HCC patients. Using 6-month mortality as the end point, the area under receiver operating characteristic curve (AUC) between the original and modified system was compared sequentially on a 3-monthly basis.

RESULTS

At the final inspection, the modified CLIP and JIS system had a significantly higher AUC compared to the original system (0.92 vs 0.893 for CLIP, P < 0.018; 0.88 vs 0.842 for JIS, P= 0.002), but there was no significant difference for the BCLC system (0.848 vs 0.841, P= 0.561). Survival analysis showed modified CLIP and JIS, and to a lesser extent, modified BCLC system, had a higher homogeneity likelihood ratio and discriminatory ability linear trend, and a lower Akaike information criterion in the Cox multivariate model, indicating a better discriminatory ability for different stage categories.

CONCLUSIONS

The MELD-based CLIP and JIS staging systems have an improved predictive ability compared to the original system and are feasible models for HCC staging in the MELD era.

Liver resection for HCC with cirrhosis: surgical perspectives out of EASL/AASLD guidelines

EASL/AASLD guidelines clearly define indications for liver surgery for HCC: patients with single HCC and completely preserved liver function without portal hypertension. These guidelines exclude from operation many patients that could benefit from radical resection and that are daily scheduled for hepatectomy in surgical centers. Patients with large tumors or with portal vein thrombosis cannot be transplanted or treated by interstitial treatments. In selected cases liver resection may obtain good long-term outcomes, significantly better than non-curative therapies. In cases of multinodular HCC, liver transplantation is the treatment of choice within Milan criteria; patients beyond these limits can benefit from liver resection, especially if only two nodules are diagnosed: even if they have a worse prognosis, survival results after liver surgery are better than those reported after TACE or conservative treatments. EASL/AASLD guidelines excluded from operating patients with portal hypertension but data about this topic are not conclusive and further studies are necessary. Selected patients with mild portal hypertension could probably be scheduled for liver resection and, considering the shortage of donors, listing for transplantation could be avoided. In conclusion, guidelines for HCC treatment should consider good results of liver resection for advanced HCC, and indications for hepatectomy should be expanded in order not to exclude from radical therapy patients that could benefit from it.

Hepatitis B viral load predicts survival of HCC patients undergoing systemic chemotherapy

HCC is a common cause of morbidity and mortality. For patients who are not candidates for curative surgery, systemic chemotherapy is one of the standard treatments. In parts of China and the Far East, over 80% of HCC patients have chronic HBV infection. In this study, we aimed to assess the relationship between pre-chemotherapy HBV viral load and the survival of HCC patients. HBV infection status was determined prior to chemotherapy in 188 patients, 170 of whom had evidence of HBV chronic infection/exposure (160 hepatitis B surface antigen [HBsAg]-positive, 10 HBsAg-negative/hepatitis B core antibody-positive). Of these, 125 had pretreatment HBV DNA levels determined via real-time PCR. Virological data were analyzed using conventional clinical variables to identify factors that influenced survival. Multivariate analysis revealed that high total bilirubin (P = 0.0016; hazard ratio = 1.040 per 1 muM increase; 95% CI 1.015-1.065), HCV infection (P = 0.0095; hazard ratio = 6.955; 95% CI 1.606-30.129), and high HBV DNA level (P = 0.0217; hazard ratio = 1.650; 95% CI 1.076-2.531) affected survival significantly. Exploratory analysis revealed that high levels of pretreatment HBV DNA had a significantly higher incidence of severe hepatitis during chemotherapy.

CONCLUSION

For HCC patients with HBV chronic infection/exposure, a high viral load prior to treatment is an adverse factor for survival and may be associated with a higher incidence of severe hepatitis during chemotherapy. Future strategies to improve the prognosis of HCC patients undergoing chemotherapy should consider supportive therapy that incorporates antiviral therapies to reduce HBV viral load.

A simple prognostic scoring system for patients with unresectable hepatocellular carcinoma treated by chemo-embolization

BACKGROUND

Hepatocellular carcinoma (HCC) comprises heterogeneous groups of patients with differing outcomes.

METHODS

In order to attempt to identify patient sub-sets, we retrospectively examined the records of 750 patients with biopsy-proven unresectable HCC, who were treated with hepatic artery chemo-embolization and were followed till death. We used the Cox proportional hazard model, as it was neutral with respect to prejudged cut-off between short and long survival.

RESULTS

On univariate analysis, we found a shorter survival to be associated with male gender, presence of cirrhosis, portal hypertension, portal vein thrombosis and elevations of bilirubin, GGTP, ALKP, AFP, DCP, PT and albumin. Five factors were found to be statistically significant (p<0.05) on multivariate analysis, namely presence of cirrhosis or ascites and elevations of AFP, ALKP or GGTP. We developed a simplified scoring system based upon the sum of the hazard ratios of each of these five factors. By combining the two factors with the heaviest hazard ratios from our multivariable analysis, namely AFP (+ = >100 ng/mL) and ALKP (+ = >100 IU/mL), we found a simple parsimonious prognostic tool, which segregated the patients into survival groups, namely AFP- ALKP-; either AFP+ or ALKP+; and AFP+ ALKP+; these three groups corresponded to a 24-month survival of 70%, 32% and 12%, respectively.

CONCLUSION

we found that only two lab functions, AFP and ALKP levels, in our large HCC patient cohort undergoing hepatic artery chemo-embolization, had prognostic significance.

Serum albumin as a significant prognostic factor for patients with gastric carcinoma

BACKGROUND

The definition of prognostic factors in gastric carcinoma (GC) remains controversial. The potential of serum albumin as a prognostic factor for GC is emphasized because the technique to measure it is simple as well as being cheap and widely available. Our aim was to define the prognostic role of serum albumin in GC.

METHODS

A cohort treated from January 1987 to December 2002 was studied. Relevant clinical, pathological and therapeutic variables were recorded. Kaplan-Meier and Cox's methods were used to define prognostic factors associated with cancer-related survival.

RESULTS

One thousand and twenty-three patients were included. Serum albumin did impact survival, showing a dose-response effect. This effect was present after adjustment for other prognostic factors, including Tumor-Node-Metastasis (TNM) stage, surgical resection and type of lymphadenectomy. In multivariate analysis, TNM stage [Stage Ia and Ib Hazard Ratio [HR] 1, Stage II HR 1.6 (95% confidence interval [CI], 0.56-4.7), Stage IIIa HR 4.4 (95% CI 1.7-11.3), Stage IIIb HR 5.6 (95% CI 2.6-17.2), Stage IV HR 6.8 (95% CI 2.7-17.5), high albumin HR 1, medium albumin HR 1.2 (95% CI 0.8-1.7), low albumin HR 1.2 (95% CI 0.8-1.8), very low albumin HR 1.8 (95% CI 1.3-2.6), D2 dissection HR 1, D1 dissection HR 1.9 (95% CI 1.3-2.97), and no resection HR 3.7 (95% CI 2.4-5.7)] were the most significant prognostic factors associated to survival (model P = 0.00001).

CONCLUSION

Pretherapeutic serum albumin level is a significant prognostic factor, which should be evaluated along with other well-defined prognostic factors in decisions concerning therapy for GC.

Staging hepatocellular carcinoma by a novel scoring system (BALAD score) based on serum markers

BACKGROUND & AIMS

Previously proposed staging systems for hepatocellular carcinoma (HCC) involve clinical, imaging, or pathologic factors in the evaluation. We established and validated a novel staging system for HCC that is based on simply serum markers.

METHODS

The new scoring system is based on 5 serum markers: bilirubin, albumin, Lens culinaris agglutinin-reactive alpha-fetoprotein (AFP-L3), alpha-fetoprotein (AFP), and des-gamma-carboxy prothrombin (DCP) and thus is termed the BALAD score. The system was validated in 2600 HCC patients from 5 institutions. The power of our system to predict patient survival and its discriminative ability were compared with those of previously reported staging systems.

RESULTS

The best tumor marker cutoff values were 400 ng/dL for AFP, 15% for AFP-L3, and 100 milli-arbitrary unit/mL for DCP. The patients were classified into 6 categories on the basis of 5 laboratory values. The categories reflected patient survival well. The discriminative ability was comparable to that of previously reported staging systems.

CONCLUSIONS

The new staging system for HCC combining serum albumin, serum bilirubin, and 3 tumor markers predicts patient outcomes with excellent discriminative ability. The system is easy to use and objective. In addition, stage can be evaluated with the use of only 1 serum sample. It also allows global comparison of patients with HCC or comparison of patients from different time periods with the same standard.

Comparison of staging systems to predict survival in hepatocellular carcinoma

PURPOSE

Some new staging systems in hepatocellular carcinoma (HCC) have been described in the last years. The aim of this study was to compare the survival-predicting capacity of some variables and the prognostic classifications.

METHODS

Demographic, clinical, analytical variables and tumour characteristics were collected in a study including 115 patients with HCC. Predictors of survival were identified using the Kaplan-Meier test and the Cox model. Comparison between different staging systems was carried out.

RESULTS

The 1-, 2- and 3-year estimated survival was 65%, 45% and 30%, respectively. Child-Pugh score and alpha-fetoprotein level greater than 400 UI/l were independent predictors of survival in the Cox model. Although all systems correctly differentiated between patients regarding survival (Kaplan-Meier, log rank < 0.05 for all), the Barcelona Clinic Liver Cancer (BCLC) showed a better discriminatory ability than the other evaluated scores. In addition, the independent homogenizing ability and stratification value of BCLC was better than that of other systems. On the contrary, model for end-stage liver disease (MELD) showed the worst results.

CONCLUSIONS

Child-Pugh score and alpha-fetoprotein levels were the only independent predictors of survival in patients with HCC. Child-Pugh score showed a better prediction value for survival when compared with MELD. BCLC is more accurate than the other prognostic models evaluated in this investigation.

Quality of life is predictive of survival in patients with unresectable hepatocellular carcinoma

BACKGROUND

Patients with unresectable hepatocellular carcinoma (HCC) have a dismal prognosis. The objective of this study was to evaluate whether patient-reported baseline quality of life (QoL) measured by the EORTC QLQ-C30 instrument is predictive of survival for these patients.

MATERIALS AND METHODS

Two hundred and thirty-three patients with unresectable HCC (mainly hepatitis B-associated) who were recruited into two separate randomized phase III clinical studies, based on palliative chemotherapy and palliative hormonal therapy, respectively, gave consent and received pretreatment QoL assessment. EORTC QLQ-C30 scores and clinical variables at the time of study entry were analyzed to identify factors that influenced survival by applying multivariate analysis. Independent prognostic factors for survival were studied by Cox regression analysis.

RESULTS

Median survival of the 233 patients was 5.5 months (95% CI 4.2-6.5 months). Significant independent predictors of shorter survival were advanced Okuda staging (P = 0.0030; HR = 2.058), high baseline total bilirubin (P = 0.0008; HR = 1.013) and worse QoL score in the appetite score domain (P = 0.0028; HR for 10 point increase = 1.070). Patients who were entered into the chemotherapy trial (P = 0.0002; HR = 0.503), those who scored better in the physical functioning domain (P = 0.0034; HR for 10 point decrease = 0.911) and the role functioning domain (P = 0.0383; HR for 10 point decrease = 0.944) of the QoL questionnaire, were associated with longer survival.

CONCLUSIONS

In the studied HCC population, patient-reported baseline QoL provides additional prognostic information that supplements traditional clinical factors, and is a new prognostic marker for survival for patients with unresectable HCC.

Modified Japan Integrated Staging is currently the best available staging system for hepatocellular carcinoma patients who have undergone hepatectomy

BACKGROUND

We previously reported the effectiveness of the modified Cancer of the Liver Italian Program (CLIP) score in hepatocellular carcinoma (HCC) staging. To determine the best predictive staging system for HCC patients, we conducted a comparative analysis of prognosis using multivariate analysis in 230 Japanese HCC patients following hepatic resection.

METHODS

We compared overall survival as predicted by different staging systems: the tumor node metastasis (TNM) system by the Liver Cancer Study Group of Japan, the Japan Integrated Staging (JIS) score (Japanese TNM and Child-Pugh classification), the modified JIS score using liver damage grade, the CLIP score, and our modified CLIP score using protein induced by vitamin K absence or the antagonist II (PIVKA-II).

RESULTS

By a univariate analysis the PIVKA-II level (cut-off level, 400 mAU/ml) was significantly associated with patient survival (P = 0.031); however, alpha-fetoprotein level was not related to survival. Liver damage grade was significantly associated with patient survival (P = 0.039), although Child-Pugh classification was not related to survival. Univariate analysis showed that prediction of survival, according to disease stage, was better with the modified JIS score than with the TNM system, CLIP, modified CLIP, or JIS score. Multivariate analysis showed the modified JIS score showed the best ability to predict overall survival according to disease stage (Hazard ratio, 1.77; P = 0.002), and its Akaike information criteria statistic was the lowest (634.3).

CONCLUSIONS

The modified JIS score, a staging system that combines tumor factors and hepatic function, is a better predictor of prognosis than other systems in HCC patients who have undergone hepatic resection.

Early liver cancer: concepts, diagnosis, and management

Hepatocellular carcinoma is a major health problem worldwide. The prognosis of patients depends on the stage when the disease is diagnosed. For the early detection of these tumors, both the selection of patients at high risk and effective surveillance programs are important. When the tumor is diagnosed early, patients can choose potentially curative treatment, including surgical resection, transplantation, and ablation therapy. Here, we give an overview of the present management of hepatocellular carcinoma. Further studies in diagnosis, treatment, and prevention are required to achieve the best clinical management of this disease.