Staging of hepatocellular carcinoma: BCLC system, what else!

Improved survival prediction and comparison of prognostic models for patients with hepatocellular carcinoma treated with sorafenib

BACKGROUND

The 'Prediction Of Survival in Advanced Sorafenib-treated HCC' (PROSASH) model addressed the heterogeneous survival of patients with hepatocellular carcinoma (HCC) treated with sorafenib in clinical trials but requires validation in daily clinical practice. This study aimed to validate, compare and optimize this model for survival prediction.

METHODS

Patients treated with sorafenib for HCC at five tertiary European centres were retrospectively staged according to the PROSASH model. In addition, the optimized PROSASH-II model was developed using the data of four centres (training set) and tested in an independent dataset. These models for overall survival (OS) were then compared with existing prognostic models.

RESULTS

The PROSASH model was validated in 445 patients, showing clear differences between the four risk groups (OS 16.9-4.6 months). A total of 920 patients (n = 615 in training set, n = 305 in validation set) were available to develop PROSASH-II. This optimized model incorporated fewer and less subjective parameters: the serum albumin, bilirubin and alpha-foetoprotein, and macrovascular invasion, extrahepatic spread and largest tumour size on imaging. Both PROSASH and PROSASH-II showed improved discrimination (C-index 0.62 and 0.63, respectively) compared with existing prognostic scores (C-index ≤0.59).

CONCLUSIONS

In HCC patients treated with sorafenib, individualized prediction of survival and risk group stratification using baseline prognostic and predictive parameters with the PROSASH model was validated. The refined PROSASH-II model performed at least as good with fewer and more objective parameters. PROSASH-II can be used as a tool for tailored treatment of HCC in daily practice and to define pre-planned subgroups for future studies.

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.

Usefulness of staging systems and prognostic scores for hepatocellular carcinoma treatments

Therapeutic management of hepatocellular carcinoma (HCC) is quite complex owing to the underlying cirrhosis and portal vein hypertension. Different scores or classification systems based on liver function and tumoral stages have been published in the recent years. If none of them is currently “universally” recognized, the Barcelona Clinic Liver Cancer (BCLC) staging system has become the reference classification system in Western countries. Based on a robust treatment algorithm associated with stage stratification, it relies on a high level of evidence. However, BCLC stage B and C HCC include a broad spectrum of tumors but are only matched with a single therapeutic option. Some experts have thus suggested to extend the indications for surgery or for transarterial chemoembolization. In clinical practice, many patients are already treated beyond the scope of recommendations. Additional alternative prognostic scores that could be applied to any therapeutic modality have been recently proposed. They could represent complementary tools to the BCLC staging system and improve the stratification of HCC patients enrolled in clinical trials, as illustrated by the NIACE score. Prospective studies are needed to compare these scores and refine their role in the decision making process.