Ascites in patients with hepatocellular carcinoma: prevalence, associated factors, prognostic impact, and staging strategy

Abstract

Purpose: Ascites may develop in patients with hepatocellular carcinoma (HCC) with coexisting liver cirrhosis. Few studies had specifically evaluated the role of ascites in HCC. This study investigated its prevalence, associated factors, prognostic impact, and staging strategy in a large HCC patient cohort.

Patients and methods: A total of 2,203 HCC patients were analyzed. The grading of ascites was according to the European Association for the Study of Liver. The prognostic ability of the Cancer of the liver Italian Program (CLIP), Barcelona Clinic Liver Cancer, Japan Integrated Scoring system, and Taipei Integrated Scoring system in HCC patients with ascites was compared using the Akaike information criterion (AIC).

Results: Ascites was present in 498 (23%) patients at diagnosis. Grades 1, 2, and 3 ascites were found in 13, 5, and 5% of the patients, respectively. The severity of ascites significantly correlated with hyperbilirubinemia, hypoalbuminemia, hyponatremia, prothrombin time (PT) prolongation, and renal insufficiency (all p < 0.001). Large tumor burden and more frequent vascular invasion were often observed in patients with more severe ascites (both p < 0.001). In the Cox proportional hazard model, ascites was identified as an independent prognostic predictor with 80-94% increased risk of mortality (p < 0.001). Among HCC patients with ascites, the CLIP system had the lowest AIC value.

Conclusions: Ascites is often seen in HCC patients and is associated with both tumoral and cirrhosis factors and decreased long-term survival. The CLIP staging system is a more feasible prognostic model for HCC patients with ascites. The optimal treatment strategy for these patients remains to be investigated.

Keywords: Ascites; Hepatocellular carcinoma; Liver cirrhosis; MELD.