Validation of the Hong Kong liver cancer staging system in hepatocellular carcinoma patients treated with curative intent

Treatment and the prognosis of hepatocellular carcinoma in Asia

Hepatocellular carcinoma is the most common type of malignant tumour in Asia. Treatment is decided according to the staging system with information on tumour burden and liver function. The Barcelona Clinic Liver Cancer staging system is the most commonly used staging system for the selection of appropriate treatments worldwide, and although it is highly evidenced-base, it has very strict guidelines for treatment. In Asian countries, many efforts have been made to expand the indications of each treatment and combination therapies as well as alternative therapies for better outcomes. The guidelines in Asia are less evidence-based than those in Western countries. More aggressive treatments for hepatocellular carcinoma are generally employed in the guidelines of Asian countries. Surgical resection is frequently employed for selected hepatocellular carcinoma patients with the Barcelona Clinic Liver Cancer stages B and C, and combination therapies are sometimes selected, which are contrary to the recommendations of American and European association for the study of the liver guidelines. Recently, a paradigm shift in treatments for advanced hepatocellular carcinoma has occurred with molecular targeted agents, antibodies and immune checkpoint inhibitors in Asia. Atezolizumab+bevacizumab therapy has become the first-line systemic treatment ineligible for radical treatment or transarterial chemoembolization in Asian countries. The overall survival of patients with hepatocellular carcinoma varies substantially across Asia. Taiwan and Japan have the best clinical outcomes for patients with hepatocellular carcinoma worldwide. Intensive surveillance programmes and the development of radical and non-radical treatments are indispensable for the improvement of prognosis in patients with hepatocellular carcinoma.

Selecting an Optimal Staging System for Intermediate-Stage Hepatocellular Carcinoma: Comparison of 9 Currently Used Prognostic Models

Purpose

It remains unknown which staging system is best in predicting the survival of patients with intermediate stage hepatocellular carcinoma (HCC). We aimed to investigate the performance of nine currently used HCC staging systems.

Patients and Methods

Between 2005 and 2014, a large cohort of 880 consecutive patients with intermediate stage HCC and sufficient data for utilization in all staging systems were enrolled. The prognostic performance of each staging system was compared. Independent prognostic variables were also identified.

Results

Multivariate analysis revealed that alkaline phosphatase (ALP), aspartate aminotransferase (AST), etiology, alpha-fetoprotein (AFP), Child-Pugh stage, tumor size, and tumor number were independent prognostic factors for survival. In the entire cohort, the Hong Kong Liver Cancer (HKLC) staging system was associated with the highest Harrell’s c-index and lowest Akaike information criterion value in comparison with other systems. In subgroup analysis according to treatment strategy, the HKLC staging system remained the best prognostic model in patients undergoing hepatic resection (n=222) or transarterial chemoembolization (n=658). Additional prognostic factors of AST, ALP, etiology, and AFP improved the discriminatory ability of HKLC.

Conclusion

The HKLC staging system is stable and consistently the best prognostic model in all patients with intermediate-stage HCC and in patients subjected to different treatment strategies. Selecting an optimal staging system is helpful in improving the design of future clinical trials in intermediate stage HCC.

A global view of hepatocellular carcinoma: trends, risk, prevention and management

Hepatocellular carcinoma (HCC) is the fourth most common cause of cancer-related death worldwide. Risk factors for HCC include chronic hepatitis B and hepatitis C, alcohol addiction, metabolic liver disease (particularly nonalcoholic fatty liver disease) and exposure to dietary toxins such as aflatoxins and aristolochic acid. All these risk factors are potentially preventable, highlighting the considerable potential of risk prevention for decreasing the global burden of HCC. HCC surveillance and early detection increase the chance of potentially curative treatment; however, HCC surveillance is substantially underutilized, even in countries with sufficient medical resources. Early-stage HCC can be treated curatively by local ablation, surgical resection or liver transplantation. Treatment selection depends on tumour characteristics, the severity of underlying liver dysfunction, age, other medical comorbidities, and available medical resources and local expertise. Catheter-based locoregional treatment is used in patients with intermediate-stage cancer. Kinase and immune checkpoint inhibitors have been shown to be effective treatment options in patients with advanced-stage HCC. Together, rational deployment of prevention, attainment of global goals for viral hepatitis eradication, and improvements in HCC surveillance and therapy hold promise for achieving a substantial reduction in the worldwide HCC burden within the next few decades.

Performance of Hong Kong Liver Cancer staging system in patients of hepatocellular carcinoma treated with surgical resection: An Indian validation study

BACKGROUND

Hong Kong Liver Cancer staging (HKLCS) system lacks external validation.

AIMS AND METHODS

We conducted a study to validate the prognostic and clinical utility of HKLCS system in the patients with hepatocellular carcinoma (HCC) of heterogeneous etiologies treated with hepatic resection with curative intent at Tata Memorial Centre, Mumbai, India.

RESULTS

A total of 144 patients underwent resection for HCC. Our patient cohort was comparable to the original developmental cohort in median age and gender distribution but differed in etiology, liver function status, and tumor venous invasion. On Kaplan-Meier survival curve analysis for overall and disease-free survival, we could achieve statistically significant separation of curves in both Barcelona Clinic Liver Cancer staging (BCLCS) and HKLCS staging systems (P < .000). Interstage discrimination between early and intermediate stages for survival was higher in HKLCS system (P value of .039 vs .091). The area under the receiver operating characteristic curve for the survival of BCLCS and HKLCS systems for the entire patient population was 0.66 and 0.60, respectively, which was not statistically significant (P = .31).

CONCLUSION

The HKLCS system offered higher interstage discrimination power in the patients with HCC treated with resection and may be equally applicable to nonalcoholic steatosis-related chronic liver disease and noncirrhotic patient population.

The Prognostic Ability of Major Hepatocellular Carcinoma Staging Systems Is Improved by Including a Treatment Variable

BACKGROUND AND AIMS

There has been significant debate regarding which hepatocellular carcinoma (HCC) staging system is best able to predict survival. We hypothesized that the prognostic ability of the Barcelona Clinic Liver Cancer (BCLC) and Hong Kong Liver Cancer (HKLC) systems would be improved with the addition of an explicit treatment variable.

METHODS

We performed an analysis of a prospectively enrolled cohort of 292 patients undergoing 532 treatment episodes for HCC from 2006 to 2014. BCLC, standard nine-stage HKLC (HKLC9), and modified five-stage HKLC (HKLC5) for each treatment episode were assessed. Overall survival and time to disease progression were calculated for the initial treatment, re-treatment, and overall treatment cohorts. We compared the performance of various prognostic models including staging system alone, treatment alone, and staging system plus treatment using the corrected Akaike information criterion and Harrell's C statistic.

RESULTS

The BCLC, HKLC5, and HKLC9 systems were significant predictors of survival and time to progression for all treatment cohorts (log rank test, p < 0.001). The addition of a treatment variable significantly improved (p < 0.01) the prognostic ability of the survival and time to progression models compared with those containing only the BCLC or HKLC stage across all treatment cohorts other than survival in re-treatment for BCLC (p = 0.094).

CONCLUSIONS

Adding a treatment variable to major HCC staging systems improves their ability to predict survival and time to progression in initial treatment, re-treatment, and overall.

HKLC Triages More Hepatocellular Carcinoma Patients to Curative Therapies Compared to BCLC and Is Associated with Better Survival

BACKGROUND AND AIMS

The Hong Kong Liver Cancer (HKLC) system proposes to triage hepatocellular carcinoma (HCC) patients to more aggressive treatment and may be associated with superior survival compared with the Barcelona Clinic Liver Cancer (BCLC) system. We aimed to identify the influence of adherence to HKLC or BCLC treatment recommendations on survival and time to progression.

METHODS

We examined a prospectively enrolled cohort of 292 patients undergoing 532 treatment episodes from a single clinical center.

RESULTS

The BCLC and HKLC systems accurately predicted overall survival and time to progression after each treatment episode (BCLC: p < 0.001; HKLC: p < 0.001). Adherence to treatment recommendations was higher for HKLC than for BCLC (55.6 vs. 47.9%, p = 0.01). Survival was superior with adherence to HKLC recommendations compared to non-adherence (45.3 vs. 27.1 months, p < 0.001). There was no difference in survival in BCLC with adherence compared to non-adherence (34.6 vs. 32.3 months, p = 0.96). The survival benefit was limited to early- and very early stage disease for both HKLC (p < 0.001) and BCLC (p = 0.007). More patients were triaged to curative therapies by HKLC than BCLC (p = 0.004). The use of transarterial chemoembolization instead of ablation or resection in early- and very early stage disease for technical reasons was the major cause for non-recommended treatment and was associated with worse survival (p < 0.001).

CONCLUSIONS

These data support the use of HKLC in early- and very early stage HCC. Efforts should be made to overcome technical reasons for not performing ablation in early- and very early stage disease.

Validation of The Hong Kong Liver Cancer Staging System in Patients with Hepatocellular Carcinoma after Curative Intent Treatment

Backgrounds:

Recently Hong Kong Liver Cancer (HKLC) staging system has been proposed for staging of hepatocellular carcinoma (HCC), and has been shown to provide better prognostic ability than the Barcelona Clinic Liver Cancer (BCLC) system. However, the HKLC system lacks external validation, and its applicability remains uncertain. The present study was aimed to evaluate the prognostic performance of HKLC in HCC patients treated with curative intent.

Methods:

Medical records of HCC patients treated with either resection or radiofrequency ablation (RFA) from 2011 to 2016 were retrospectively reviewed. The overall survival and the prognostic ability of the HKLC and BCLC system were evaluated.

Results:

79 HCC patients were included, of which 64.56% had Child A cirrhosis. Chronic viral hepatitis B infection was the leading cause of HCC, followed by chronic viral hepatitis C infection, alcohol and alcohol with HBV or HCV infection. According to the BCLC system, 82.28% were in stage 0-A, and according to the HKLC system, 93.67% were in stage I-IIb. RFA and liver resection were the primary treatment in 56.96% and 43.04%, respectively. The 5-year survival rate of patients in HKLC stage I, IIa and IIb were 81.64%, 61.66%, and 54.42%, respectively (P<0.001). Whereas, the 5-year survival rate of patients in BCLC stage 0, A and B were 60.00%, 75.90%, and 26.65%, respectively (P=0.053). The AUROC curve of the HKLC and BCLC for the entire cohort was 0.77 and 0.64, respectively (P=0.15). Subgroup analysis showed the AUROC curve of the HKLC and BCLC for the patients with viral-associated HCC was 0.79 and 0.68, respectively (P=0.02).

Conclusions:

Applying the HKLC staging system provides a good discriminative ability for survival prediction in HCC patients treated with curative intent. Comparing with the BCLC system, the HKLC system tends to yield better prognostic accuracy, particularly in viral-associated HCC.