What is the Best HCC Staging System for People Being Treated with Transarterial Chemoembolization (TACE)?

A new study suggests the Barcelona Clinic Liver Cancer (BCLC) system offers more prognostic benefit than other hepatocellular carcinoma (HCC) staging systems for predicting overall survival rates in patients who undergo transarterial chemoembolization (TACE).

For the comparative study, recently published in Clinical Imaging, researchers compared five HCC staging systems in a cohort of 317 HCC patients treated with conventional TACE or drug-eluting beads (DEB) TACE. In addition to the BCLC system, researchers also assessed the Hong Kong Liver Cancer (HKLC), Japan Integrated Staging (JIS), Okuda and Cancer of the Liver Italian Program (CLIP) staging systems.

The study authors found that the BCLC staging system provided the highest likelihood ratio (LR) (26.639) for prognostic stratification and a significantly lower Akaike information criterion (AIC) — which facilitates prediction error estimates — (317) in comparison to the other HCC staging systems.

“ … The BCLC staging system is the most applicable in predicting the outcome of patients after they received TACE therapy. Specifically, this is the case for patients presenting with EtOH (ethyl alcohol) or HCV (Hepatitis C virus)-related etiologies, due to the prevalence of these etiologies in this population,” wrote lead study author Victor Kasolowsky, M.D., who is affiliated with the Department of Radiology and Biomedical Imaging at the Yale School of Medicine in New Haven, Ct., and colleagues.

However, the researchers noted that the HKLC staging system had a higher linear trend (LT) than the HCLC system for quantifying survival differences between stages (10.919 vs. 8.201) and a higher C-index (83.5 percent vs. 81.8 percent)

Pointing out “significant heterogeneity” in patients staged as having intermediate or advanced HCC stages with the BCLC system, the study authors said the HKLC system offers improved clarity with disease extent.

“The Hong Kong Liver Cancer (HKLC) staging system was designed to increase the cohort stratification, reflecting a more nuanced approach to the extent of disease while slightly limiting the weight of liver function and disease etiology,” added Kasolowsky and colleagues.

Emphasizing caution with respect to the HKLC system, the researchers said this staging system was primarily based on patients with hepatitis B virus (HBV)-related liver disease and noted a lack of clarity with validation of the system in Western populations.

The JIS system had the lowest LT (4.611), the lowest C-index (54.8 percent) and the second-highest AIC (449) out of the five HCC staging systems for prognostic stratification in patients treated with TACE, according to the study authors.

(Editor’s note: For related content, see “Current Perspectives on the BCLC Staging System for Hepatocellular Carcinoma,” “Can a CT Radiomics Model Improve Risk Assessment for Macrotrabecular-Massive Hepatocellular Carcinoma?” and “Emerging Model with Key MRI Feature Improves Prediction for Advanced Recurrence of Hepatocellular Carcinoma.”)

Beyond the inherent limitations of a single-center retrospective study, the authors acknowledged that the cohort included patients who received TACE as a first-line therapy, a second-line therapy or as a salvage treatment.