Abstract
BackgroundA consensus on the most reliable staging system for hepatocellular carcinoma (HCC) is still lacking but the most used is a revised Barcelona Clinic Liver Cancer (BCLC) system, adopted by the American Association for the Study of Liver Diseases (AASLD). We investigated how many patients are diagnosed in "very early" and "early" stage, follow the AASLD guidelines for treatment and whether their survival depends on treatment.MethodsData were collected in 530 "very early" and "early" HCC patients recruited by a multicentric Italian collaborative group (ITA.LI.CA). The Kaplan-Meier method was used to estimate overall survival and the log rank to test the statistical significance of difference between groups. Cox's multivariate stepwise regression analysis was used to pinpoint independent prognostic factors and the adjusted relative risks (hazard ratios) were calculated as well. A statistical analysis based on the chi-square test was used to identify significant differences in clinical or pathological features between patients. A P-value < 0.05 was considered statistically significant.Results"Very early" HCC were 3%; Cox multivariate analysis did not identify variables independently associated with survival. The patients following AASLD recommendations (20%) did not show longer survival. In "early" HCC patients (25%), treatment significantly modulated survival (p = 0.0001); the 28% patients treated according to the AASLD criteria survived longer (p = 0,004). The Cox analysis however identified only age, gender, number of lesions and Child class as independent predictors of survival.Conclusionpatients with very early" HCC were very few in this analysis. In most instances they were not treated with the treatment suggested as the most appropriate by the AASLD guidelines and the type of treatment had no impact on survival, even though the number of patients was relatively low and part of the patients were diagnosed before the introduction of the guidelines: this analysis, therefore, might not be considered as conclusive and should be validated. The "early" stage group involved more patients, rarely treated according to the guidelines, both overall and also in those diagnosed after their publication; the survival was in part predicted by the type of treatment, with better results in those treated according to AASLD indications.
Highlights
A consensus on the most reliable staging system for hepatocellular carcinoma (HCC) is still lacking but the most used is a revised Barcelona Clinic Liver Cancer (BCLC) system, adopted by the American Association for the Study of Liver Diseases (AASLD)
The modality of cancer diagnosis was defined as "surveillance" when HCC was detected during routine follow-up (6-monthly or yearly clinical examination and imaging), "incidental" when an asymptomatic neoplasm was discovered outside a surveillance program, and "symptomatic" when HCC was diagnosed because of the onset of symptoms
It is generally accepted that the Cancer of the Liver Italian Program (CLIP) system works better for advanced HCC and the BCLC for early disease undergoing surgery and in non cirrhotics [19,20]
Summary
Data were collected in 530 "very early" and "early" HCC patients recruited by a multicentric Italian collaborative group (ITA.LI.CA). A statistical analysis based on the chi-square test was used to identify significant differences in clinical or pathological features between patients. This study retrospectively analyzed data collected prospectively concerning 1834 HCC patients (482 females, 1352 males) recruited from January 1986 to December 2004 at 10 clinical institutions forming the ITA.LI.CA (Italian Liver Cancer) group. The diagnosis of HCC was histologically confirmed in 939 cases In the remainder, it was based on the guidelines on HCC management, and obtained by at least two imaging techniques with typical features for HCC or combining a diagnostic increase in alfa-fetoprotein (AFP) (> 200 ng/mL) with typical features detected by one imaging technique [14]. We considered portal hypertension (as clinically suggested by the presence of esophageal varices) or bilirubine level < 2 mg/dl as exclusion criteria for resection
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