An independent evaluation of modern prognostic scores in a central European cohort of 120 patients with hepatocellular carcinoma

Applicability of scoring systems predicting outcome of transarterial chemoembolization for hepatocellular carcinoma

PURPOSE

Several scoring systems have been proposed to predict the outcome of transarterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC). However, the application of these scores to a bridging to transplant setting is poorly validated. Evaluation of the applicability of prognostic scores for patients undergoing TACE in palliative intention vs. bridging therapy to liver transplantation (LT) is necessary.

METHODS

Between 2008 and 2017, 148 patients with HCC received 492 completed TACE procedures (158 for bridging to transplant; 334 TACE procedures in palliative treatment intention at our center and were analyzed retrospectively. Scores (ART, CLIP, ALBI, APRI, SNACOR, HAP, STATE score, Child-Pugh, MELD, Okuda and BCLC) were calculated and evaluated for prediction of overall survival. ROC analysis was performed to assess prediction of 3-year survival and treatment discontinuation.

RESULTS

In patients receiving TACE in palliative intention most scores predicted OS in univariate analysis but only mSNACOR score (p = 0.006), State score (p < 0.001) and Child-Pugh score (p < 0.001) revealed statistical significance in the multivariate analysis. In the bridging to LT cohort only the BCLC score revealed statistical significance (p = 0.002).

CONCLUSIONS

Clinical usability of suggested scoring systems for TACE might be limited depending on the individual patient cohorts and the indication. Especially in patients receiving TACE as bridging to LT none of the scores showed sufficiently applicability. In our study Child-Pugh score, STATE score and mSNACOR score showed the best performance assessing OS in patients with TACE as palliative therapy.

HBV infection and hepatocellular carcinoma

The hepatitis B virus (HBV) plays a dominant role in the 749,000 new cases and 692,000 deaths related to hepatocellular carcinoma (HCC) that are estimated to occur each year worldwide. Chronic infection with HBV is responsible for 60% of HCCs in Asia and Africa and at least 20% of the tumors in Europe, Japan, and the United States. This article discusses the pathogenic role of HBV and the risk of HCC. Tumors almost invariably develop in the context of chronic hepatitis or cirrhosis, which makes early diagnosis the only practical approach to improve prognosis. The treatment options are also discussed.

Outcome of patients with hepatocellular carcinoma referred to a tertiary centre with availability of multiple treatment options including cadaveric liver transplantation

Hepatocellular carcinoma (HCC) is a primary cancer of the liver with an established causal link to viral hepatitis and other forms of chronic liver disease.

AIMS

The aim of this study was to analyse the determinants of outcome in patients with HCC referred to a tertiary centre for management.

METHOD

Two hundred and thirty-five prospective patients with HCC and minimum 12-month follow-up were studied.

RESULTS

The cohort was heterogeneous, with 52% Caucasian, 40% Asian and 5% of Middle-Eastern origin. Independent predictors of outcome included tumour size and number, the presence of ascites or portal vein thrombosis, alpha-foetoprotein >50 U/L and an impaired performance status. Treatment was determined on an individual case basis by a multidisciplinary tumour team. Surgical resection was primary treatment in 43 patients, liver transplantation in 40 patients, local ablation (percutaneous radiofrequency ablation or alcohol injection) in 33 patients, transarterial chemoembolisation in 33 patients, chemotherapy or other systemic therapy in 30 patients and no treatment in 56 patients. After adjustment for significant covariates, both liver transplantation (P<0.001) and surgical resection (P=0.029) had a significant effect on patient survival compared with no treatment, but local ablation (P=0.410) and chemoembolisation (P=0.831) did not. Liver transplantation resulted in superior overall and, in particular, disease-free survival compared with surgical resection (disease-free survival 84 vs 15% at 5 years).

CONCLUSION

In conclusion, both surgical resection and liver transplantation significantly improve the survival of patients with HCC, but improvements need to be made to the delivery of loco-regional therapy to enhance its effectiveness.

A novel prognostic nomogram is more accurate than conventional staging systems for predicting survival after resection of hepatocellular carcinoma

BACKGROUND

Prediction of survival after resection of hepatocellular carcinoma (HCC) remains difficult. Numerous staging systems have been devised for purposes of risk classification; we sought to identify the optimal staging system to predict postoperative survival.

STUDY DESIGN

One hundred eighty-four patients who underwent primary complete resection of HCC at our institution between 1989 and 2002 were classified according to 8 contemporary staging systems. The ability of these systems to predict relative survival for randomly selected pairs of patients was quantified using the Harrel's concordance index. A novel prognostic nomogram was constructed using prognostically relevant variables.

RESULTS

After a median followup of 46 months for surviving patients, the median overall survival was 38 months. The concordance indices for the existing staging systems ranged from 0.54 to 0.59. Only the 2002 American Joint Commission on Cancer system demonstrated a concordance index with a 95% confidence interval exceeding 0.5, indicating that the ability of conventional systems to predict relative survival of randomly selected pairs of patients was generally no better than chance. We developed a novel nomogram based on patient age, serum alpha-fetoprotein level, operative blood loss, resection margin status, tumor size, satellite lesions, and vascular invasion. The nomogram demonstrated a markedly superior concordance index of 0.74 (95% CI, 0.68 to 0.80). A separate nomogram for prediction of recurrence-free survival was also generated.

CONCLUSIONS

Contemporary staging systems for HCC do not accurately predict postoperative outcomes. Our prognostic nomogram provides a mechanism for accurate prediction of survival and risk stratification and will require validation at other hepatobiliary centers.

Comparison of clinical staging systems in predicting survival of hepatocellular carcinoma patients receiving major or minor hepatectomy

AIM

To compare the utility of seven commonly used staging systems in the prediction of survival among patients with hepatocellular carcinoma (HCC) undergoing major or minor hepatectomy.

METHODS

All patients were classified by the Okuda, the TNM, the CLIP, the BCLC, the CUPI, the JIS and the MELD classifications to estimate the probabilities of survival. Survival curves were calculated using the Kaplan-Meier method and were examined using log-rank testing. The overall predictive power for patient survival with each staging system was evaluated using linear trend chi(2) tests and from the area under the receiver operating characteristic (ROC) curve.

RESULTS

In our patient cohort, the log-rank test and the linear trend chi(2) test of the CLIP and JIS systems gave better results than did the other staging systems. The discriminatory ability of the CLIP and JIS staging for death, evaluated by ROC curve areas, was also better. In the subgroups of major hepatectomy patients with a non-cirrhotic liver or minor hepatectomy patients with a cirrhotic liver, the CLIP and JIS systems showed similar better performances in these three tests. The discriminatory ability of the CLIP system was the best in major hepatectomy patients with a non-cirrhotic liver while JIS score discriminated best in minor hepatectomy patients with a cirrhotic liver.

CONCLUSION

Among the seven staging systems, the CLIP and JIS systems perform better than do the others. While the CLIP system should be considered to stage major hepatectomy patients, the JIS system could be chosen to stage minor hepatectomy patients.

Prospective validation of the Barcelona Clinic Liver Cancer staging system

BACKGROUND/AIMS

The Barcelona Clinic Liver Cancer (BCLC) classification offers a prognostic stratification of patients with hepatocellular carcinoma (HCC). We recently demonstrated the BCLC's peculiar prognostic ability in a retrospective cohort of HCC patients. The aim of this study was to evaluate the BCLC system prospectively in a subsequent separate group of HCC patients enrolled at the same surgically oriented liver unit.

METHODS

One hundred and ninety-five consecutive HCC patients were prospectively enrolled and their liver disease was staged before therapy. Unlike the BCLC treatment protocol, nodule size and number were not used as absolute exclusion criteria for radical treatment. Predictors of survival were identified using the Cox model.

RESULTS

The median survival time was 23 months overall, and 53, 16, 7 and 3 months, respectively, for BCLC categories A, B, C, and D. In our cohort, BCLC had the best independent predictive power for survival when compared with the Okuda, CLIP, UNOS-TNM, and JIS prognostic systems (linear trend chi(2)=43.01, likelihood chi(2)=57.94, AIC 885.98). Moreover, the BCLC classification showed a better prognostic ability than the AJCC-TNM 2002 system in surgical patients.

CONCLUSIONS

The discriminating power of BCLC staging was prospectively assessed in an Italian cohort of HCC patients treated mainly with radical therapies.

Prognostic effects of causative virus in hepatocellular carcinoma according to the Japan integrated staging (JIS) score

BACKGROUND

The Japan integrated staging (JIS) score is recognized to be useful in managing hepatocellular carcinoma (HCC). We evaluated the effects of the causative virus in patients stratified by this system.

METHODS

We compared clinicopathologic features, cumulative and tumor-free survival rates, and causes of death between 301 hepatitis C virus-positive patients (HCV group) and 60 hepatitis B virus-positive patients (HBV group).

RESULTS

Among patients with low JIS scores (0 or 1), the proportions of patients with high aspartate and alanine aminotranferase activities, moderate-to-severe active hepatitis, and with cirrhosis were significantly higher in the HCV than in the HBV group. Among patients with high JIS scores (2 to 4), the proportion with moderate-to-severe active hepatitis was also significantly higher in the HCV group. In patients with low JIS scores, those in the HCV group had significantly lower tumor-free and cumulative survival rates than those in the HBV group. Although no patient in the HBV group died of causes other than liver disease (HCC or hepatic failure), some patients in the HCV group died of causes other than liver disease. The proportion of patients who died because of HCC recurrence tended to be higher among patients with high JIS scores than among patients with a low JIS score.

CONCLUSIONS

The effects of viral status on survival outcomes are greatest in patients with JIS scores of 0 or 1.

Natural history of hepatocellular carcinoma

The natural history of hepatocellular carcinoma is variable. In many patients the tumor has a long-lasting subclinical incubation period and often grows as a solitary mass to a size at which it can be detected by ultrasound. In other patients, however, the onset of the tumor is multinodal with great variations in the growth rates. Prognostication of patients with hepatocellular carcinoma takes into account the size and number of tumor nodes and their relation to the portal veins, and the degree of liver impairment.

Staging systems in hepatocellular carcinoma

Staging systems are key to predict the prognosis of patients with cancer, to stratify the patients according to prognostic variables in the setting of clinical trials, to allow the exchange of information among researchers, and finally to guide the therapeutic approach. The current knowledge of the disease, however, prevents recommendation of a staging system that can be used world-wide. The conventional staging systems for hepatocellular carcinoma (HCC), such as the Okuda stage or the TNM stage have shown important limitations in classifying patients. Several new systems have been proposed recently, and only three of them have been validated at this point. The BCLC staging classification links the stage of the disease to a specific treatment strategy. The JIS score has been proposed and used in Japan, although it needs Western validation. The CLIP score is used in patients with advanced tumors. Several reasons explain the difficulty in identifying a world-wide system. First, HCC is a complex neoplasm inserted on a pre-neoplastic cirrhotic liver, and thus variables of both diseases leading to death should be taken into account. Second, the disease is very heterogeneous around the world, and this reflects different underlying epidemiological backgrounds and risk factors. Third, HCC is the sole cancer treated by transplantation in a small proportion of patients. Fourth, only around 20% of the cases are currently treated by surgery, thus precluding the wide use of pathology-based systems, such as TNM. Finally, the potential relevance of a molecular signature identified in terms of outcome prediction is unknown, and further research is needed to obtain this valuable biological information that may aid in classifying the patients.