Usefulness of staging systems and prognostic scores for hepatocellular carcinoma treatments

Abstract

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.

Keywords: Barcelona Clinic Liver Cancer staging system; Hepatocellular carcinoma; NIACE; Scoring system; Transarterial chemoembolization.

Figure 1

Common parameters between hepatocellular carcinoma classifications and scores. AFP: Alpha-fetoprotein; CLIP: Cancer of the Liver Italian Program; BCLC: Barcelona Clinic Liver Cancer; JIS: Japan Integrated Staging; HKLC: Hong Kong Liver Cancer; TIS: Taipei Integrated Scoring System; ECOG (PS): Eastern Cooperative Oncology Group (performance status).

Figure 2

Barcelona Clinic Liver Cancer system. HCC: Hepatocellular carcinoma; PS: Performance status; TACE: Transarterial chemoembolization.

Figure 3

Asian Pacific Association for the Study of the Liver guidelines on the treatment algorithm for hepatocellular carcinoma. HCC: Hepatocellular carcinoma; TACE: Transarterial chemoembolization; RFA: Radiofrequency ablation.

Figure 4

Hong Kong Liver Cancer classification. EVM: Extrahepatic vascular invasion/metastasis; BSC: Best supportive care; TACE: Transarterial chemoembolization; ECOG: Eastern Cooperative Oncology Group.

Figure 5

Evolution of the median overall survival according to the NIACE score in Barcelona Clinic Liver Cancer stage C patients from a French multicenter study, treated by sorafenib (black bars center 2, grey bars center 3, white bars center 4)[38]. BCLC: Barcelona Clinic Liver Cancer.

Figure 6

Evolution of the median overall survival according to the NIACE score in hepatocellular carcinoma patients from a French multicenter study treated by transarterial chemoembolization (grey bars center 1, black bars center 2)[60]. TACE: Transarterial chemoembolization.

Figure 7

Prognostic scores designed to transarterial chemoembolization, an aid to the decision making process: In practice. BCLC: Barcelona Clinic Liver Cancer; HCC: Hepatocellular carcinoma; TACE: Transarterial chemoembolization; CT: Computed tomography; ART: Assessment for Retreatment with TACE; ECOG (PS), Eastern Cooperative Oncology Group (Performance Status); RFA: Radiofrequency ablation; HAP: Hepatoma Arterial-embolisation Prognostic; MRI: Magnetic resonance imaging.

Figure 8

Nomogram for hepatocellular carcinoma recurrence after radiofrequency ablation[67].

Figure 9

Evolution of the median overall survival according to the NIACE score in hepatocellular carcinoma patients from a French multicenter study treated by surgery/radiofrequency ablation (grey bars center 5, black bars center 1)[68]. RFA: Radiofrequency ablation.