Staging of hepatocellular carcinoma
Authors: Timothy M. Pawlik, Eddie K. Abdalla, Melanie Thomas, Mark S. Roh, Gregory Y. Lauwers, Dario Ribero, Ronnie T. Poon, Jacques Belghiti, David M. Nagorney, Jean Nicolas Vauthey, Jorge A. Marrero, Robert J. Fontana, Grace L. Su, Hari S. Conjeevaram, Anna S. Lok
Journal: Hepatology (2005)

In the April issue of HEPATOLOGY, Marrero et al.1 reported that the Barcelona Clinic Liver Cancer (BCLC) "staging classification" provided the best prognostic stratification for patients with hepatocellular carcinoma (HCC). Their staging validation, however, is limited by critical shortcomings. The BCLC algorithm prescribes palliative therapies (ablation, chemoembolization) to many patients who may be candidates for resection. The University of Michigan (UM) algorithm similarly excludes patients from potentially curative therapy by using the same criteria. The retrospective application of such a treatment-based "staging" to their patients predictably showed that the outcomes of the BCLC and UM algorithms are congruous. The proof that the algorithms from UM and BCLC predict prognosis based on treatment and not by disease is the disparity in survival for patients who met the Milan criteria. Both groups propose either transplantation or ablation for patients with a solitary tumor ≤ 5 cm or up to 3 tumors ≤ 3 cm, but Fig, 2B reveals significantly different survival based not on disease, but rather only on treatment—the best survival in the transplantation group, the worst survival in the ablation group—despite different treatments being given to patients with the same disease (stage A in BCLC algorithm). Although the authors state that the study groups were "balanced," the treatments do not reflect this; most patients in the study had advanced disease (cirrhosis, 98%; multiple tumors, 56%) and only 4% underwent resection. Given that 100 patients were Child-Turcotte-Pugh Classification A, and 222 had unilateral disease, potentially curative resection might have been offered to a significant subgroup. For example, patients with solitary HCC > 5 cm or multiple tumors > 3 cm (stage B in BCLC algorithm) might have been considered for resection, but were instead treated exclusively with chemoembolization. Such palliative treatment is not consistent with the existing approach taken at many major hepatobiliary centers. Ng et al.2 reported a 5-year survival rate of 39% after resection of large or multinodular HCC (Stage B in BCLC algorithm). Pawlik et al.3 reported a 5-year survival rate of 27% after resection in well-selected patients with HCC measuring ≥10 cm. These results suggest that the use of strict morphological criteria to exclude patients from surgical consideration is inappropriate. Categorical exclusion of patients from resection, as proposed by the BCLC and by Marrero et al.,1 also precludes identification of factors predictive of survival or selection factors for optimal treatment if that therapy is not undertaken. In 2002, the AJCC/UICC adopted a simplified staging for HCC.4 This staging was based on a detailed evaluation of tumor and liver factors associated with HCC. The study included patients from hepatobiliary centers in Japan, France, and the United States.5 More recently, this staging was independently validated in eastern and western patients undergoing resection for HCC.6-8 We agree with Marrero et al. that the lack of a consensus on HCC staging hinders progress in critical areas of HCC research. However, given the heterogeneity of patients with HCC, a need remains for alternate stagings and treatment algorithms. Timothy M. Pawlik*, Eddie K. Abdalla*, Melanie Thomas , Mark S. Roh , Gregory Y. Lauwers?, Dario Ribero*, Ronnie T. Poon?, Jacques Belghiti**, David M. Nagorney , Jean-Nicolas Vauthey*, * Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX, Department of Gastrointestinal Medical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX, Department of Surgical Oncology, Allegheny General Hospital, Pittsburgh, PA, ? Department of Gastrointestinal Pathology, Massachusetts General Hospital, Boston, MA, ? Department of Surgery, Queen Mary Hospital, Hong Kong, China, ** Department of Surgery, Hospital Beaujon, Paris, France, Department of General Surgery, Mayo Clinic, Rochester, MN.