Hong Kong Liver Cancer Staging Research Articles

Ideal patients for liver resection in Barcelona Clinic Liver Cancer or Hong Kong Liver clinic systems for hepatocellular carcinoma: Conservative or aggressive?

BackgroundBoth the Barcelona Clinic Liver Cancer (BCLC) staging and the Hong Kong Liver Cancer (HKLC) staging have their own definitions of ideal patients for liver resection (IPLR) in hepatocellular carcinoma (HCC). This study aimed to compare the prognosis of IPLRs between the BCLC and HKLC staging systems, and to identify patients who may benefit from liver resection (LR) in the HKLC staging but beyond the BCLC staging.MethodsThis retrospective study evaluated 1,296 consecutive patients with HCC who underwent LR between August 2013 and April 2021 (457 patients and 1,046 patients were IPLR according to the BCLC and HKLC staging systems, respectively). Overall survival (OS) was compared between the two groups. To assess potential benefit of LR for IPLR in the HKLC staging but beyond the BCLC staging, univariate and multivariate Cox regression analysis was performed to determine prognostic factors of OS, and prognostic stratification was performed based on the selected prognostic factors. The IPLRs in the HKLC staging but beyond the BCLC staging were divided into subgroups according to the prognostic stratification and separately compared with the IPLRs in the BCLC staging.ResultsOS was different between the two staging systems (P = 0.011). All the 457 IPLRs in the BCLC staging were also the IPLRs in the HKLC staging. Diameter of the largest tumor5 cm (HR = 1.58; 95% CI: 1.18–2.10; P = 0.002) and liver cirrhosis (HR = 1.61; 95% CI: 1.19–2.20; P = 0.002) were risk factors for poor OS in IPLRs in the HKLC staging but beyond the BCLC staging; hence, patients were divided into the low-risk (n = 104), intermediate-risk (n = 369), and high-risk groups (n = 116) accordingly. There was no difference in OS between patients in the BCLC staging and patients in low-risk group (P = 0.996). However, OS was significantly different between patients in the BCLC staging and those in intermediate-risk (P = 0.003) and high-risk groups (P < 0.001).ConclusionIPLRs in the BCLC staging system have better prognosis. However, IPLRs in the HKLC staging system but beyond the BCLC staging may have equivalent prognosis to IPLRs in the BCLC staging if the tumor size is ≤ 5 cm and liver cirrhosis is absent.

Prognostic Value of Microvascular Invasion in Eight Existing Staging Systems for Hepatocellular Carcinoma: A Bi-Centeric Retrospective Cohort Study.

BackgroundMicrovascular invasion (MVI) is a significant risk factor affecting survival outcomes of patients after R0 liver resection (LR) for hepatocellular carcinoma (HCC). However, whether the existing staging systems of hepatocellular carcinoma can distinguish the prognosis of patients with MVI and the prognostic value of MVI in different subtypes of hepatocellular carcinoma remains to be clarified.MethodsA dual-center retrospective data set of 1,198 HCC patients who underwent R0 LR was included in the study between 2014 and 2016. Baseline characteristics and staging information were collected. Homogeneity and modified Akaike information criterion (AICc) were compared between each system. And the prognostic significance of MVI for overall survival (OS) was studied in each subgroup.ResultsIn the entire cohort, there were no significant survival differences between Cancer of the Liver Italian Program (CLIP) score 2 and 3 (p = 0.441), and between Taipei Integrated Scoring System (TIS) score 3 and 4 (p = 0.135). In the MVI cohort, there were no significant survival differences between Barcelona Clinic Liver Cancer stages B and C (p=0.161), CLIP scores 2 and 3 (p = 0.083), TIS scores 0 and 1 (p = 0.227), TIS scores 2 and 3 (p =0.794), Tokyo scores 3 and 4 (p=0.353), and American Joint Committee on Cancer Tumor-Node-Metastasis 7th stage I and II (p=0.151). Among the eight commonly used HCC staging systems, the Hong Kong Liver Cancer (HKLC) staging system showed the highest homogeneity and the lowest AICc value in both the entire cohort and MVI cohort. In each subgroup of the staging systems, MVI generally exhibited poor survival outcomes.ConclusionsThe HKLC staging system was the most accurate model for discriminating the prognosis of MVI patients, among the eight staging systems. Meanwhile, our findings suggest that MVI may be needed to be incorporated into the current HCC staging systems as one of the grading criteria.

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

PurposeIt 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 MethodsBetween 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.ResultsMultivariate 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.ConclusionThe 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.

"Six-and-twelve" score for outcome prediction of hepatocellular carcinoma following transarterial chemoembolization. In-depth analysis from a multicenter French cohort.

The “six-and-twelve” (6&12) score is a new hepatocellular carcinoma (HCC) prognostic index designed for recommended transarterial chemoembolization (TACE) candidates. Quick and easy to use by the sum of tumor size (cm) and number, this model identifies three groups with different survival time (the sum is ≤ 6; or > 6 but ≤ 12; or > 12); a survival benefit with TACE can be expected for HCC patients with a score not exceeding twelve. Recently, Wang ZW et al showed that the “6&12” model was the best system correlated with radiological response after the first TACE. Thus, we wanted to assess its survival prediction ability as well as its prognostic value and compared it to other systems (Barcelona Clinic Liver Cancer, Hong Kong Liver Cancer (HKLC) staging, Albumin-Bilirubin grade, tumor nodularity, infiltrative nature of the tumor, alpha-fetoprotein, Child-Pugh class, and Performance Status score, Cancer of the Liver Italian Program, Model to Estimate Survival for HCC scores, up-to-seven criteria) different from Wang ZW et al study in a multicenter French cohort of HCC including only recommended TACE candidates retrospectively enrolled. As previously demonstrated, we show that the "6&12” score can classify survival within this French cohort, with a prognostic value comparable to that of other systems, except HKLC staging. More importantly, the “6&12” score simplicity and ability in patients’ stratification outperform other systems for a routine clinical practice.

Hepatocellular carcinoma staging systems: Hong Kong liver cancer vs Barcelona clinic liver cancer in a Western population.

BACKGROUNDDespite being the world’s most widely used system for staging and therapeutic guidance in hepatocellular carcinoma (HCC) treatment, the Barcelona clinic liver cancer (BCLC) system has limitations, especially regarding intermediate-grade (BCLC-B) tumors. The recently proposed Hong Kong liver cancer (HKLC) staging system appears useful but requires validation in Western populations.AIMTo evaluate the agreement between BCLC and HKLC staging on the management of HCC in a Western population, estimating the overall patient survival.METHODSThis was a retrospective study of HCC patients treated at a university hospital in southern Brazil between 2011 and 2016. Demographic, clinical, and laboratory data were collected. HCC staging was carried out according to the HKLC and BCLC systems to assess treatment agreement. Overall survival was estimated based on the treatment proposed in each system.RESULTSA total of 519 HCC patients were assessed. Of these, 178 (34.3%) were HKLC-I; 95 (18.3%) HKLC-IIA; 47 (9.1%) HKLC-IIB; 29 (5.6%) HKLC-IIIA; 30 (5.8%) HKLC-IIIB; 75 (14.4%) HKLC-IV; and 65 (12.5%) HKLC-V. According to the BCLC, 25 (4.9%) were BCLC-0; 246 (47.4%) BCLC-A; 107 (20.6%) BCLC-B; 76 (14.6%) BCLC-C; and 65 (12.5%) BCLC-D. The general agreement between the two systems was 80.0% - BCLC-0 and HKLC-I (100%); BCLC-A and HKLC-I/HKLC-II (96.7%); BCLC-B and HKLC-III (46.7%); BCLC-C and HKLC-IV (98.7%); BCLC-D and HKLC-V (41.5%). When sub-classifying BCLC-A, HKLC-IIB, HKLC-IIIA and HKLC-IIIB stages according to the up-to-7 in/out criterion, 13.4, 66.0, 100 and 36.7%, respectively, of the cases were classified as up-to-7 out.CONCLUSIONIn a Western population, the general agreement between the two systems was 80.0%, although in BCLC-B cases the agreement was low, suggesting that some individuals could be candidates for the curative treatment recommended by the HKLC. The authors suggest that the BCLC system should be routinely employed, although for BCLC-B cases it should be associated with the HKLC system.

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

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

Staging systems of hepatocellular carcinoma: A review.

Staging of hepatocellular carcinoma (HCC) is necessary for guiding prognostication, management, and research purposes that further aid in the improvement of existing clinical and epidemiological health services. Though there are some new staging systems for HCC developed in different parts of the world, there is no globally accepted staging system that allows for comparison of current management protocols among heterogeneous populations. In this review, we discuss the evolution and applicability in clinical practice of different clinical staging systems of HCC-Okuda, CLIP (Cancer of the Liver Italian Program) score, MESIAH (Model to Estimate Survival In Ambulatory HCC patients) score, ITA.LI.CA (Italian Liver Cancer) score, BCLC (Barcelona Clinic Liver Cancer) staging, HKLC (Hong Kong Liver Cancer) staging, and the Alberta algorithm. This review aims to highlight the main criteria for assessing the prognosis of HCC that these different staging systems take into account, their strengths and limitations for use in modern clinical practice. Despite the limitations of the BCLC staging system, it remains the most validated and reliable system for prognostication. However, there is a need to update the BCLC staging system to include recent data on locoregional and systemic therapies for HCC, expanded criteria for transplantation, and systemic therapy for hepatitis C infection.

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.

Validity of the Barcelona clinic liver cancer (BCLC) and Hong Kong liver cancer (HKLC) staging system in determining treatment for hepatocellular carcinoma (HCC) in Singapore

Various staging systems have been introduced to stage and guide the therapeutic approach in patients diagnosed with HCC. The goal of our study is to compare paradigms in the HCC staging system, specifically, the BCLC and HKLC system, and to ultimately determine which framework Tan Tock Seng Hospital (TTSH), Singapore, employs more often. Generally, the HKLC algorithm provides a more refined staging and offers more aggressive treatments than the BCLC algorithm. A retrospective analysis was done, in which patients diagnosed with HCC at TTSH between 2010 and 2015 were identified and staged according to both the BCLC and HKLC staging system. The offered treatment was recorded and compared against the recommended treatment algorithm corresponding to each staging framework. Through this comparison, we determined which algorithm was followed by the hospital, if any at all. 779 patients were identified and in 475 (60.8%) cases, either the BCLC or HKLC was followed. 155 (19.9%) patients exclusively used the treatment algorithm recommended by HKLC while 78 (10.0%) patients exclusively followed the treatment algorithm recommended by BCLC. In the cases that exclusively followed the HKLC system, more aggressive treatments were offered than if the BCLC algorithm had been followed instead. In 242 (31.1%) cases, both algorithms recommend the same treatment modality and hence, these patients followed both staging systems. Finally, the treatment offered to 304 (39.0%) patients did not correspond to either of the staging systems. In general, the HKLC staging system was adopted by the hospital in a higher percentage of cases.

Assessment of the Hong Kong Liver Cancer Staging System in Europe

European and American guidelines have endorsed the Barcelona Clinic Liver Cancer (BCLC) staging system. The aim of this study was to assess the performance of the recently developed Hong Kong Liver Cancer (HKLC) classification as a staging system for hepatocellular carcinoma (HCC) in Europe. We used a pooled set of 1693 HCC patients combining three prospective European cohorts. Discrimination ability between the nine substages and five stages of the HKLC classification system was assessed. To evaluate the predictive power of the HKLC and BCLC staging systems on overall survival, Nagelkerke pseudo R2, Bayesian Information Criterion and Harrell's concordance index were calculated. The number of patients who would benefit from a curative therapy was assessed for both staging systems. The HKLC classification in nine substages shows suboptimal discrimination between the staging groups. The classification in five stages shows better discrimination between groups. However, the BCLC classification performs better than the HKLC classification in the ability to predict overall survival (OS). The HKLC treatment algorithm tags significantly more patients to curative therapy than the BCLC. The BCLC staging system performs better for European patients than the HKLC staging system in predicting OS. Twice more patients are eligible for a curative therapy with the HKLC algorithm; whether this translates in survival benefit remains to be investigated.

Impact of current staging systems on treatment strategy for HBV-related hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer and the second leading cause of cancer-related death worldwide. HCC incidence has increased over the last few years, with more than half of HCC cases being reported in China, where hepatitis B virus (HBV) infection is the main etiologic factor. The heterogeneity in HCC's worldwide distribution and the differences in its etiology in different locations may result in prognosis estimation and therapeutic decision making being more complicated for HCC patients. In the past decade, several clinical staging systems have been developed based on relevant prognostic factors. Among them, the Barcelona Clinic Liver Cancer (BCLC) and Hong Kong Liver Cancer (HKLC) staging systems are the only two classification systems that link prognostic classification to treatment indications. In this review, we mainly focus on the use of the BCLC and HKLC staging systems for guiding therapeutic decision making for HCC, the respective advantages and disadvantages of each classification system, and future perspectives for the improvement of the HKLC model.

O052 : Assessment of the hong kong liver cancer staging system in europe

O052 : Assessment of the hong kong liver cancer staging system in europe