Prognostic factors for survival in patients with early-intermediate hepatocellular carcinoma undergoing non-surgical therapy: comparison of Okuda, CLIP, and BCLC staging systems in a single Italian centre

Abstract

Background: Several prognostic models have been developed to stage hepatocellular carcinoma (HCC) but there is no general consensus on which is the most reliable. We compared three prognostic indices (Okuda, CLIP, and BCLC scoring systems) in a large series of cirrhotic patients with HCC undergoing non-surgical treatment in terms of their ability to classify patients into different risk groups

Methods: We retrospectively studied 268 Italian patients with HCC. A total of 146 patients were treated with ablation, 132 with percutaneous ethanol injection, and 14 with radiofrequency ablation; 103 underwent transcatheter arterial chemoembolisation and 19 had supportive care alone. Factors determining survival were analysed by univariate and multivariate analysis using the Kaplan-Meier method and Cox proportional hazard regression models. Okuda, CLIP, and BCLC scores evaluated before treatment were applied.

Results: Median survival was 25.7 months. In a multivariate analysis, portal vein thrombosis, alpha fetoprotein, total bilirubin, and tumour size were significant predictors of survival. Okuda, CLIP, and BCLC scores were all able to predict survival (p<0.001). They identified two, four, and six risk groups, respectively, with a median survival ranging from 27 to 19 months for Okuda, 30 to 5 months for CLIP, and 43 to 7 months for BCLC.

Conclusions: Both CLIP and BCLC scores were more effective than the Okuda score in stratifying patients into different risk groups with early-intermediate HCC. However, the BCLC scoring system gave a better prediction of prognosis in patients with disease diagnosis at a very early stage.

Figure 1

Overall survival of 268 patients with hepatocellular carcinoma included in the study (Kaplan-Meier method). Median survival was 25.7 months.

Figure 2

(A, B) Kaplan-Meier estimated survival curves by Barcelona Clinic Liver Cancer (BCLC) score of patients classified as stage I and stage II using the Okuda score system. (A) Okuda I: BCLC A1 v A2 p = 0.003; A2 v A3 p = 0.035; A3 v A4 p = 0.303; A4 v B p = 0.139; B v C p = 0.932. (B) Okuda II: BCLC A4 v B p<0.001; B v C p = 0.044. MS, median survival (months).

Figure 3

(A, B) Kaplan-Meier estimated survival curves by Cancer of the Liver Italian Program (CLIP) score of patients classified as stage I and stage II using the Okuda score system. (A) Okuda I: CLIP 0 v 1 p = 0.102; 1 v 2 p = 0.080. (B) Okuda II: CLIP 0 v 1 p = 0.013; 1 v 2 p = 0.682; 2 v 3 p = 0.271; 3 v 4 p = 0.208. MS, median survival (months).