Staging and prognostic factors in hepatocellular carcinoma
- Steven A Curley, MD, FACS
Steven A Curley, MD, FACS
- Professor of Surgery
- Baylor College of Medicine
- Carlton C Barnett, Jr, MD
Carlton C Barnett, Jr, MD
- Professor of Surgery
- University of Colorado at Denver
- Eddie K Abdalla, MD
Eddie K Abdalla, MD
- Professor of Surgery
- The Lebanese American University
Hepatocellular carcinoma (HCC) is an aggressive tumor that frequently occurs in the setting of chronic liver disease and cirrhosis. (See "Epidemiology and etiologic associations of hepatocellular carcinoma".) It is typically diagnosed late in the course of these diseases, and the median survival following diagnosis ranges from approximately 6 to 20 months . Available therapeutic options for HCC are dictated by the complex interplay of tumor stage and the extent of underlying liver disease.
This topic review will provide an overview of staging and prognostic scoring systems for HCC. Surgical and nonsurgical treatments for HCC are discussed separately. (See "Overview of treatment approaches for hepatocellular carcinoma".)
STAGING AND PROGNOSTIC SCORING SYSTEMS
A number of systems have been proposed to predict the prognosis for hepatocellular carcinoma (HCC), none of which has been universally adopted [2-8]. These schema variably incorporate four features that have been recognized as being important determinants of survival: the severity of underlying liver disease, the size of the tumor, extension of the tumor into adjacent structures, and the presence of metastases [2,3,9-11]; some (eg, the Hong Kong and French prognostic staging systems) also incorporate performance status [5,8]. The four most commonly used systems are the tumor, node, metastasis (TNM), Okuda and Barcelona Clinic Liver Cancer (BCLC) systems, and the Cancer of the Liver Italian Program (CLIP) score. A new, evidence-based score – the ALBI (albumin-bilirubin) grade – if independently validated, may allow more objective assessment of the severity of liver dysfunction in patients with HCC across a wide spectrum of treatments. (See 'ALBI score' below.)
Tumor, node, metastasis (TNM) staging — The current combined TNM staging classification of the American Joint Committee on Cancer (AJCC)/Union for international Cancer Control (UICC) was revised in 2010 (table 1) . Like the 2002 classification, this system recognizes the most important predictors of prognosis: the number of tumors, and the presence and extent of vascular invasion within the tumor [13,14]. However, compared with the 2002 staging system, there are some reclassification changes, primarily surrounding the better prognosis for multiple HCC versus HCC with major vascular invasion.
Five-year survival rates after complete resection for HCC, based upon the 2010 TNM staging system, are as follows :
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- STAGING AND PROGNOSTIC SCORING SYSTEMS
- Tumor, node, metastasis (TNM) staging
- Okuda system
- CLIP score
- The Barcelona staging classification
- ALBI score
- RETREAT and MoRAL scores
- Choice of staging system
- OTHER FACTORS INFLUENCING SURVIVAL
- High versus low-incidence regions
- Tumor histology
- Serum alpha-fetoprotein level
- Variant estrogen receptors
- Hepatitis B and C
- - Antiviral therapy for HBV-related HCC
- Diabetes mellitus
- New prognostic markers under investigation
- Clinical implications