A new prognostic classification scheme with treatment guidelines for Asian patients with hepatocellular carcinoma (HCC): the Hong Kong Combined Liver Cancer (HKCLC) classification

Abstract

BACKGROUND: HCC patients in Asia mostly have different etiologies and have different treatment algorithm when compared with their Western counterparts. Despite the wide use in Western countries, the Barcelona Clinic Liver Cancer (BCLC) staging may not fit in the management of Asian patients. We aim to develop a new prognostic classification scheme with treatment guidelines for Asian HCC patients. METHODS: HCC patients treated at the Department of Surgery, Queen Mary Hospital between 1995 and 2008 were included. The scheme was developed by both statistical methodology and clinical judgment. Four established prognostic factors, namely ECOG PS, Child-Pugh grade, tumor status and presence of extrahepatic venous invasion/metastasis, were selected in building the scheme. A scoring system which assigns 'points' to each category of these 4 factors was developed using Cox regression on overall survival. The points and combined scores were referred to stratify patients to different staging with specific treatment recommendations. RESULTS: 3,617 patients were identified. The scheme stratifies patients to stages I to V with distinct overall survival outcomes. Selected patients had benefited from more aggressive treatments than what were recommended in BCLC. In patients who were classified as stage B in BCLC but I/II in HKCLC, the survival benefit of radical curative therapies over TACE was substantial (5-year survival probability: 0.479 vs 0.175; P<0.0001 by log-rank test). Similarly, in patients who were classified as stage C in BCLC but I/II in HKCLC, the survival benefit of radical curative therapies over systemic therapy was even more pronounced (5-year survival probability: 0.484 vs 0; P<0.0001 by log-rank test). Furthermore, in patients who were classified as stage C in BCLC but III in HKCLC, the survival benefit of TACE over systemic therapy was also significant (3-year survival probability: 0.087 vs 0.011; P<0.0001 by log-rank test). CONCLUSIONS: The HKCLC scheme may be able to identify patients suitable for treatments more aggressive than BCLC’s recommendations and thus yield a better survival outcome.