Published online Sep 27, 2019. doi: 10.4254/wjh.v11.i9.678
Peer-review started: May 29, 2019
First decision: June 13, 2019
Revised: July 8, 2019
Accepted: August 20, 2019
Article in press: August 20, 2019
Published online: September 27, 2019
Treating patients with hepatocellular carcinoma (HCC) is not simple, since two serious diseases usually coincide: Cirrhosis and a malignant tumor. The Barcelona clinic liver cancer (BCLC) staging system, is the most widely used and endorsed system in Western HCC management guidelines. The Hong Kong liver cancer (HKLC) staging system identifies subsets of patients with intermediate and advanced HCC and proposes more aggressive treatment; however, this system still requires validation in Western populations. This study to assess the agreement of BCLC and HKLC therapeutic approaches according to HCC evolutionary stage in this population.
Evaluating the agreement of the treatments proposed by the BCLC and HKLC system according to HCC evolutionary stage in a Western population, can optimize the therapeutic approaches, promoting an increase in patient survival time.
This study aimed first to evaluate the agreement between BCLC and HKLC staging on the management of HCC in a Western population. Secondary aim was estimating the overall patient survival with HCC.
Retrospective cross-sectional study analyzed data from the medical records of individuals over 18 years of age diagnosed with HCC and treated at a referral service in a university hospital in southern Brazil between 2011 and 2016. Upon diagnosis, demographic and clinical data and laboratory results were collected, as well as performance status and Child-Pugh (CP) scores. Diagnosis was based on the American Association for the Study of the Liver Diseases criteria. The patients were staged according to BCLC criteria and HKLC system. After, the agreement of the treatment proposed by both systems was performed. Overall patient survival was estimated from HCC diagnosis until the outcome, i.e., death, loss of follow-up, or the date of the last appointment at the referral hospital.
A total of 519 HCC patients were assessed. Of these, 178 (34.3%) were HKLC-I; 95 (18.3%) HKLC-IIA; 47 (9.1%) HKLC-IIB; 29 (5.6%) HKLC-IIIA; 30 (5.8%) HKLC-IIIB; 75 (14.4%) HKLC-IV; and 65 (12.5%) HKLC-V. According to the BCLC, 25 (4.9%) were BCLC-0; 246 (47.4%) BCLC-A; 107 (20.6%) BCLC-B; 76 (14.6%) BCLC-C; and 65 (12.5%) BCLC-D. The general agreement between the two systems was 80.0% - BCLC-0 and HKLC-I (100%); BCLC-A and HKLC-I/HKLC-II (96.7%); BCLC-B and HKLC-III (46.7%); BCLC-C and HKLC-IV (98.7%); BCLC-D and HKLC-V (41.5%). When sub-classifying BCLC-A, HKLC-IIB, HKLC-IIIA and HKLC-IIIB stages according to the up-to-7 in/out criterion, 13.4, 66.0, 100 and 36.7%, respectively, of the cases were classified as up-to-7 out.
This study showed that there is adequate agreement between the BCLC and HKLC staging systems (80.0%) regarding therapeutic management of HCC in Western populations, although in BCLC-B cases the agreement was low, suggesting that some individuals could be candidates for the curative treatment recommended by the HKLC. However, it is clear that both systems have limitations to determine when curative treatment should be recommended. Although staging systems should be further refined to cover the full diversity of HCC cases, these findings suggest that the BCLC system should be routinely employed in Western populations; although for BCLC-B cases it should be associated with the HKLC system.
Demonstrated adequate agreement between the BCLC and HKLC systems in relation to the therapeutic management of HCC in Western population evaluated. However, new multicenter and prospective studies are needed to assess this issue in the Western population.