Prognosis of Patients with Hepatocellular Carcinoma. Validation and Ranking of Established Staging-Systems in a Large Western HCC-Cohort

Abstract

BackgroundHCC is diagnosed in approximately half a million people per year, worldwide. Staging is a more complex issue than in most other cancer entities and, mainly due to unique geographic characteristics of the disease, no universally accepted staging system exists to date. Focusing on survival rates we analyzed demographic, etiological, clinical, laboratory and tumor characteristics of HCC-patients in our institution and applied the common staging systems. Furthermore we aimed at identifying the most suitable of the current staging systems for predicting survival.Methodology/Principal FindingsOverall, 405 patients with HCC were identified from an electronic medical record database. The following seven staging systems were applied and ranked according to their ability to predict survival by using the Akaike information criterion (AIC) and the concordance-index (c-index): BCLC, CLIP, GETCH, JIS, Okuda, TNM and Child-Pugh. Separately, every single variable of each staging system was tested for prognostic meaning in uni- and multivariate analysis. Alcoholic cirrhosis (44.4%) was the leading etiological factor followed by viral hepatitis C (18.8%). Median survival was 18.1 months (95%-CI: 15.2–22.2). Ascites, bilirubin, alkaline phosphatase, AFP, number of tumor nodes and the BCLC tumor extension remained independent prognostic factors in multivariate analysis. Overall, all of the tested staging systems showed a reasonable discriminatory ability. CLIP (closely followed by JIS) was the top-ranked score in terms of prognostic capability with the best values of the AIC and c-index (AIC 2286, c-index 0.71), surpassing other established staging systems like BCLC (AIC 2343, c-index 0.66). The unidimensional scores TNM (AIC 2342, c-index 0.64) and Child-Pugh (AIC 2369, c-index 0.63) performed in an inferior fashion.Conclusions/SignificanceCompared with six other staging systems, the CLIP-score was identified as the most suitable staging system for predicting prognosis in a large German cohort of predominantly non-surgical HCC-patients.

Prognosis of unresectable hepatocellular carcinoma: Comparison of seven staging systems (TNM, Okuda, BCLC, CLIP, CUPI, JIS, CIS) in a Chinese cohort.

“…The CLIP system has been externally validated in Korean [11], Taiwanese [12], French [13], Japanese [29], American [14], German [15] cohorts. However, a study of 4525 patients in Japan had reached opposite conclusions that stratification ability and prognostic predictive power of the JIS score were much better than that of the CLIP score [9].…”

“…Many studies comparing staging systems in HCC have revealed different ranking of staging systems [11][12][13][14][15][16][17]. However, these studies included patients with early to advanced stages, or only early to intermediate stage, or only advance stage of HCC, whereas our studied population included patients with intermediate to advanced disease that is not amenable to radical treatment.…”

“…Other staging systems (except for CIS staging) have been compared and ranked in different studies [11][12][13][14][15][16][17] according to their prognostic value. Results were not consistent between studies.…”

Changes in Healthcare-Associated Staphylococcus aureus Bloodstream Infections after the Introduction of a National Hand Hygiene Initiative

“…An advantage of using the AIC is that the best fitting model is chosen regardless of the statistical significance (or otherwise) of any change in infection rates. The AIC is a useful statistic for quantifying the evidence for a set of competing models, 19 and it has been used in a wide variety of model selection problems, including choosing between competing sets of independent variables, 20 prediction models, 21 and covariance structures. 22 For the best model in each state, we estimated the per- figure 3.…”

The Addition of C-Reactive Protein to Validated Staging Systems Improves Their Prognostic Ability in Patients with Hepatocellular Carcinoma

“…In fact, the BCLC classification has been validated in different clinical settings [8,9,10,11]. However, recent studies from Taiwan and Germany have demonstrated that the CLIP system is the best prognostic model in patients with HCC [12,13,14]. Therefore, it remains unclear which of these staging systems can most accurately predict the prognosis of patients with HCC.…”