S. Bergstresser2, P. Li2, K. Vines2, B. Comeaux1, D. DuBay3, S. Gray1,2, D. Eckhoff1,2, J. White1,2 1University Of Alabama at Birmingham,Department Of Surgery, Division Of Transplantation,Birmingham, Alabama, USA 2University Of Alabama at Birmingham,School Of Medicine,Birmingham, Alabama, USA 3Medical University Of South Carolina,Department Of Surgery, Division Of Transplantation,Charleston, Sc, USA
Introduction: Hepatocellular carcinoma (HCC) is the third most common cause of cancer related deaths worldwide. As the incidence of HCC continues to trend upwards, it is imperative to have validated staging systems to guide clinicians when choosing treatment options. Seven HCC staging systems have been validated to varying degrees, however, there is currently inadequate evidence in the literature regarding which system is the best predictor of survival. The purpose of this investigation was to determine predictors of survival and compare the 7 staging systems in their ability to predict survival in a cohort of patients diagnosed with HCC.
Methods: This is a prospectively controlled chart review study of 782 patients diagnosed with HCC between January 2007 and April 2015 at a large, single-center hospital. Lab values, patient demographics, and tumor characteristics were used to stage patients and calculate Model for End Stage Liver Disease (MELD) and Child-Pugh scores. Kaplan-Meier method and log-rank test were used to identify the risk factors of overall survival. Cox regression model was used to calculate linear trend χ 2 and likelihood ratio χ 2 to determine linear trend and homogeneity of the staging systems, respectively.
Results: Univariate analyses suggested that tumor number (P < .0001), diameter of largest lesion (P < .0001), tumor taking up > 50% of liver mass (P < .0001), tumor major vessel involvement (P = .0025), alpha fetoprotein level (AFP) 21-200 vs > 200 (P < .0001), and Child Pugh score (P <.0001) were significant predictors of overall survival; while portal hypertension (P= .520) and pre-intervention bilirubin (P= .0904) were not. In all patients, the Cancer of Liver Italian Program (CLIP) provided the largest linear trend χ 2 and likelihood ratio χ 2 in the Cox model when compared to other staging systems, indicating the best predictive power for survival.
Conclusion:Based on our statistical analysis, Child Pugh score, tumor size, number, presence of vascular invasion, and AFP level play a significant role in determining survival. In all patients and in patients receiving treatment other than transplantation (ablation, chemoembolization), CLIP appears to be the best predictor of survival. The CLIP staging system takes into account Child Pugh score, tumor morphology, AFP level, and portal vein thrombosis, which may explain its significant ability to predict survival.
