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Abstract: Accurately staging patients is essential to oncology practice. Cancer staging contributes to
prognostication, guides management decisions, and informs clinical, epidemiologic, and health services
research. In hepatocellular carcinoma (HCC), staging poses unique challenges due to the geographic and
biological heterogeneity of the disease and lack of consensus on how to best classify patients. The features
included in various HCC classifications systems have evolved over the last 50 years, but in general, need to
account for both tumor characteristics as well as the burden of underlying liver disease.
In this review, we discuss the Child-Turcotte-Pugh and Model for End-Stage Liver Disease, two practical
systems that reflect the degree of hepatic dysfunction. We then describe several HCC staging systems,
reviewing their development, and applicability to clinical practice, with a critical look at their validation.
Finally, we look ahead to novel systems utilizing molecular markers. It is hoped this review will provide
context regarding the use of current staging and scoring methods and a glimpse of what we can expect with
future systems.
Submitted Jun 20, 2013. Accepted for publication Jul 16, 2013.
doi: 10.3978/j.issn.2304-3865.2013.07.05
Scan to your mobile device or view this article at: http://www.thecco.net/article/view/2528/3943
© Chinese Clinical Oncology. All rights reserved. www.thecco.net Chin Clin Oncol 2013;2(4):33
Page 2 of 12 Subramaniam et al. HCC staging systems
information from a pathological examination. This reflects codified in the Child-Turcotte publication in 1964 (5), where
the fact that biopsy may not be a pre-requisite to diagnosis patients being considered for surgery for portal venous
of HCC (3). Serum alpha-fetoprotein (AFP) is a commonly- shunting were risk-stratified into three categories. The
used screening biomarker in patients at risk for HCC but initial Child-Turcotte staging included clinical assessments
is not sufficient for surveillance or diagnosis due to lack of of encephalopathy, ascites, nutritional status and laboratory
sensitivity and specificity (4). Although retrospective data measurements of serum bilirubin and albumin and then
have established high AFP at presentation as a negative was modified by Pugh in 1973 (6), with the replacement of
prognostic factor, serum AFP level is included in only a nutritional status by prothrombin time (Table 2).
subset of HCC staging systems (Table 1). The CTP score is the simplest and most widely used
For a staging system to be effective and widely used, grading system for liver function. Given that most HCCs
it has to be reliable, reproducible and simple, using data arise in the milieu of cirrhosis, and surgical interventions
elements that can be obtained as part of standard clinical have the highest potential of cure, CTP is ubiquitous in
practice across a wide range of treatment sites. Most HCC the evaluation of HCC. In addition to routine clinical
staging systems have identified prognostic factors through and research use, the CTP score is referenced routinely
multivariate analyses of large cohorts of patients to weight by regulatory agencies reviewing new drug applications.
the different variables according to prognostic impact. Once However, the drawbacks are many, including inter-
proposed, a classification system must be validated across laboratory variations, day-to-day fluctuations in the key
the spectrum of HCC cohorts. parameters and the subjective nature of the clinical grading
We will first review the principal system used to score of encephalopathy and ascites (7). Though the CTP score
underlying liver function in cirrhotic patients, the Childs- by itself does not include any HCC-specific parameters, it
Turcotte-Pugh score (CTP). Next we consider the Model has been incorporated into multiple contemporary scoring
for End-Stage Liver Disease (MELD), which predicts short- systems including Cancer of the Liver Italian Program
term prognosis and is extensively used in liver transplant (CLIP) and Barcelona Clinic Liver Cancer (BCLC).
evaluation. We then examine seven commonly-utilized
HCC staging systems with respect to their development and
Model for end stage liver disease (MELD)
limitations. Finally, we will look ahead to novel molecular
and biomarker-based staging systems which we hope will The MELD score, initially developed to determine
enable us to refine our understanding and classification of prognosis following a transjugular intra-hepatic shunt
this complex and heterogeneous cancer. (TIPS) procedure for liver failure (8), is now widely used
in the liver transplant arena to prioritize donor liver
allocation. It is a logarithmic score that is comprised of
Child-Turcotte-Pugh (CTP)
International Normalized Ratio (INR), serum creatinine,
The prognostic importance of liver function was first total serum bilirubin and the etiology of cirrhosis. After
© Chinese Clinical Oncology. All rights reserved. www.thecco.net Chin Clin Oncol 2013;2(4):33
Chinese Clinical Oncology, Vol 2, No 4 December 2013 Page 3 of 12
Figure 1 Model for end-stage liver disease (MELD) model, Overview of current staging systems
UNOS modification.
TNM
© Chinese Clinical Oncology. All rights reserved. www.thecco.net Chin Clin Oncol 2013;2(4):33
Page 4 of 12 Subramaniam et al. HCC staging systems
Table 3 American Joint Committee on Cancer (AJCC) TNM Staging for Liver Tumors (7th ed., 2010) (1)
Primary tumor (T)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
T1 Solitary tumor without vascular invasion
T2 Solitary tumor with vascular invasion or multiple tumors none more than 5 cm
T3a Multiple tumors more than 5 cm
T3b Single tumor or multiple tumors of any size involving a major branch of the portal vein or hepatic vein
T4 Tumors with direct invasion of adjacent organs other than the gallbladder or with perforation of visceral peritoneum
Regional lymph nodes (N)
NX Regional lymph nodes cannot be assessed
N0 No regional node metastasis
N1 Regional lymph node metastasis
Distant metastasis (M)
M0 No distant metastasis
M1 Distant metastasis
Anatomic stage/prognostic groups
Stage I T1 N0 M0
Stage II T2 N0 M0
Stage IIIA T3a N0 M0
Stage IIIB T3b N0 M0
Stage IIIC T4 N0 M0
Stage IVA Any T N1 M0
Stage IVB Any T Any N M1
Histologic grade (G)
G1 Well differentiated
G2 Moderately differentiated
G3 Poorly differentiated
G4 Undifferentiated
Fibrosis score (F)
The fibrosis score as defined by Ishak recommended because of its prognostic value in overall survival. This scoring system uses
a 0-6 scale
F0 Fibrosis score 0-4 (none to moderate fibrosis)
F1 Fibrosis score 5-6 (severe fibrosis or cirrhosis)
value to patient assessment. It has little relevance to patients the degree of underlying cirrhosis. Using a cohort of 850
presenting with advanced disease because of the model’s patients with an unequivocal diagnosis of HCC between
inability to reflect the prognosis of underlying liver disease. 1975-1983, Okuda and colleagues devised a staging system
based on four factors representing advanced disease. This
includes tumor occupying greater or less than 50% of the
Okuda score
liver, the presence or absence of ascites, and serum albumin
The Okuda system is a prognostic score introduced in and bilirubin levels (Table 4). In the original cohort, median
1985 (23) and incorporates both tumor features as well as survival was 11.5 months for Stage I, 3.0 months for Stage
© Chinese Clinical Oncology. All rights reserved. www.thecco.net Chin Clin Oncol 2013;2(4):33
Chinese Clinical Oncology, Vol 2, No 4 December 2013 Page 5 of 12
CLIP score
BCLC staging classification
The CLIP score was proposed in 1998 and by incorporating
The BCLC classification was first published in 1999 (24) Child-Pugh stage, tumor morphology, AFP level and the
and is considered the standard HCC system by the presence or absence of portal vein thrombosis, takes into
American Association of for the Study of Liver Disease account both liver function and tumor characteristics (34)
(AASLD) (4) and European Association for the Study of (Table 7). However, what constitutes “massive” is subjective,
the Liver (25). These endorsements and the substantial without specific size criteria.
contributions to HCC research by the hepatologists who To derive the score, a retrospective analysis was
described BCLC sometimes disguise the reality that not performed between 1990-1992 of 435 HCC consecutive
every clinician and researcher in the field agrees with the patients, almost all with cirrhosis, presenting to the 16
stance of the distinguished liver societies. CLIP institutions. Univariate analysis identified significant
Derived from a single institution experience, BCLC predictors of overall survival, and these were included into
takes into account size and extent of the primary tumor, a stratified Cox proportional hazards regression model,
liver function and physiological factors and incorporates with loco-regional therapy as the stratification factor.
the Okuda stage and Child-Pugh score (Table 5). There is a The majority of patients (56.8%) received some form of
corresponding treatment schedule for each stage (Table 6), loco-regional treatment and only a few (2.7%) underwent
ranging from curative therapies such as resection or surgery.
transplant for early stage patients to best supportive care The CLIP score (range from 0-5) was first validated
© Chinese Clinical Oncology. All rights reserved. www.thecco.net Chin Clin Oncol 2013;2(4):33
Page 6 of 12 Subramaniam et al. HCC staging systems
Table 6 Treatment schedule proposed for hepatocellular carcinoma (HCC) cirrhotic patients according to the BCLC classification system
Stage Treatment intention First/second choice
Stage A: early HCC
A1 Radical Surgical resection
A2 Surgical resection → OLT/percutaneous treatment
A3 OLT/percutaneous treatment
A4 OLT/percutaneous treatment
Stage B: intermediate HCC Palliative* Transarterial embolization (associated or not to percutaneous treatment)
chemoembolization
Stage C: advanced HCC Palliative* New agents
Stage D: end-stage HCC Symptomatic Supportive treatment
*In the setting of phase II investigations or randomized control trials.
by the original investigators on a prospective cohort of 174 predominantly Hepatitis B positive patients with HCC
196 HCC patients with cirrhosis being enrolled in a who underwent curative resection (39). The CLIP score
clinical trial (35) and has subsequently been validated also performed better than other prognostication systems
on Japanese, Canadian and German cohorts of patients when used to retrospectively analyze 131 Korean patients,
(36-38). CLIP was found to be a good predictor of with unresectable HCC, who were undergoing transarterial
recurrence in a retrospective analysis of a Chinese cohort of chemoembolization (TACE) (40).
© Chinese Clinical Oncology. All rights reserved. www.thecco.net Chin Clin Oncol 2013;2(4):33
Chinese Clinical Oncology, Vol 2, No 4 December 2013 Page 7 of 12
Table 8 Japan integrated staging (JIS) scoring system Table 9 Weight of six prognostic factors in Chinese University
Scores Prognostic Index (CUPI)
Variables
0 1 2 3 Variable Weight
Child-Pugh stage A B C TNM Stage
TNM stage by LCSGJ I II III IV I and II –3
LCSGJ, Liver Cancer Study Group of Japan. IIIa and IIIb –1
IVa and IVb (reference) 0
Asymptomatic disease on presentation –4
Ascites 3
The CLIP score is not flawless. The paucity of patients
AFP ≥500 ng/mL 2
undergoing curative surgery in the original cohort may
limit its ability to prognosticate early stage patients. Total bilirubin (µmol/L)
© Chinese Clinical Oncology. All rights reserved. www.thecco.net Chin Clin Oncol 2013;2(4):33
Page 8 of 12 Subramaniam et al. HCC staging systems
The heterogeneous nature of HCC has made it difficult Over the past decade, numerous molecular signatures have
© Chinese Clinical Oncology. All rights reserved. www.thecco.net Chin Clin Oncol 2013;2(4):33
Chinese Clinical Oncology, Vol 2, No 4 December 2013 Page 9 of 12
been proposed to predict recurrence and cancer outcomes allow us to improve our prognostic ability and deliver more
in surgically resected HCC (58,60). In 2011, Villanueva effective care to patients with HCC.
et al. evaluated 22 different molecular signatures and
identified 2—the G3 signature from tumor and the poor-
Acknowledgements
survival signature from adjacent nontumoral cirrhotic
tissue—which, together with clinico-pathological features, Disclosure: The authors declare no conflict of interest.
were associated with recurrence (61).
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