Background Although the Barcelona Clinic Liver Cancer (BCLC) staging system has been largely adopted in clinical practice, recent studies have emphasized the need for further refinement and subclassification of this system. Methods Patients who underwent hepatectomy with curative intent for BCLC‐0, ‐A or ‐B hepatocellular carcinoma (HCC) between 2000 and 2017 were identified using a multi‐institutional database. The tumour burden score (TBS) was calculated, and overall survival (OS) was examined in relation to TBS and BCLC stage. Results Among 1053 patients, 63 (6·0 per cent) had BCLC‐0, 826 (78·4 per cent) BCLC‐A and 164 (15·6 per cent) had BCLC‐B HCC. OS worsened incrementally with higher TBS (5‐year OS 77·9, 61 and 39 per cent for low, medium and high TBS respectively; P < 0·001). No differences in OS were noted among patients with similar TBS, irrespective of BCLC stage (61·6 versus 58·9 per cent for BCLC‐A/medium TBS versus BCLC‐B/medium TBS, P = 0·930; 45 versus 13 per cent for BCLC‐A/high TBS versus BCLC‐B/high TBS, P = 0·175). Patients with BCLC‐B HCC and a medium TBS had better OS than those with BCLC‐A disease and a high TBS (58·9 versus 45 per cent; P = 0·005). On multivariable analysis, TBS remained associated with OS among patients with BCLC‐A (medium TBS: hazard ratio (HR) 2·07, 95 per cent c.i. 1·42 to 3·02, P < 0·001; high TBS: HR 4·05, 2·40 to 6·82, P < 0·001) and BCLC‐B (high TBS: HR 3·85, 2·03 to 7·30; P < 0·001) HCC. TBS could also stratify prognosis among patients in an external validation cohort (5‐year OS 79, 51·2 and 28 per cent for low, medium and high TBS respectively; P = 0·010). Conclusion The prognosis of patients with HCC varied according to the BCLC stage but was largely dependent on the TBS.

Introduction Intrahepatic cholangiocarcinoma (ICC) remains an uncommon disease with a rising incidence worldwide. We sought to identify trends in therapeutic approaches and differences in patient outcomes based on facility types. Methods Between January 1, 2004, and December 31, 2015, a total of 27,120 patients with histologic diagnosis of ICC were identified in the National Cancer Database and were enrolled in this study. Results The incidence of ICC patients increased from 1194 in 2004 to 3821 in 2015 with an average annual increase of 4.16% (p \ 0.001). Median survival of the cohort improved over the last 6 years of the study period (2004-2009: 8.05 months vs. 2010-2015: 9.49 months; p \ 0.001). Among surgical patients (n = 5943, 21.9%), the incidence of R0 resection, lymphadenectomy and harvest of C6 lymph nodes increased over time (p \ 0.001). Positive surgical margins (referent R0: R1, HR 1.49, 95% CI 1.24-1.79, p \ 0.001) and treatment at community cancer centers (referent academic centers; HR 1.24, 95% CI 1.04-1.49, p = 0.023) were associated with a worse prognosis. Patients treated at academic centers had higher rates of R0 resection (72.4% vs. 67.7%; p = 0.006) and lymphadenectomy (55.6% vs. 49.5%, p = 0.009) versus community cancer centers. Overall survival was also better at academic versus community cancer programs (median OS: 11 months versus 6 months, respectively; p \ 0.001). Conclusions The incidence of ICC has increased over the last 12 years in the USA with a moderate improvement in survival over time. Treatment at academic cancer centers was associated with higher R0 resection and lymphadenectomy rates, as well as improved OS for patients with ICC.Lu Wu and Diamantis I. Tsilimigras contributed equally to this work.

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