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Multicenter Study
, 13 (5), 557-568

A Proposal for Modification of the Barcelona Clinic Liver Cancer Staging System Considering the Prognostic Implication of Performance Status

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Multicenter Study

A Proposal for Modification of the Barcelona Clinic Liver Cancer Staging System Considering the Prognostic Implication of Performance Status

Hyo Jung Cho et al. Gut Liver.

Abstract

Background/aims: Barcelona Clinic Liver Cancer (BCLC) C stage demonstrates considerable heterogeneity because it includes patients with either symptomatic tumors (performance status [PS], 1-2) or with an invasive tumoral pattern reflected by the presence of vascular invasion (VI) or extrahepatic spread (EHS). This study aimed to derive a more relevant staging system by modification of the BCLC system considering the prognostic implication of PS.

Methods: A total of 7,501 subjects who were registered in the Korean multicenter hepatocellular carcinoma (HCC) registry database from 2008 to 2013 were analyzed. The relative goodness-of-fit between staging systems was compared using the Akaike information criterion (AIC) and integrated area under the curve (IAUC). Three modified BCLC (m-BCLC) systems (#1, #2, and #3) were devised by reducing the role of PS.

Results: As a result, the BCLC C stage, which includes patients with PS 1-2 without VI/EHS, was reassigned to stage 0, A, or B according to their tumor burden in the m-BCLC #2 model. This model was identified as the most explanatory and desirable model for HCC staging by demonstrating the smallest AIC (AIC=70,088.01) and the largest IAUC (IAUC=0.722), while the original BCLC showed the largest AIC (AIC=70,697.17) and the smallest IAUC (IAUC=0.705). The m-BCLC #2 stage C was further subclassified into C1, C2, C3, and C4 according to the Child-Pugh score, PS, presence of EHS, and tumor extent. The C1 to C4 subgroups showed significantly different overall survival distribution between groups (p<0.001).

Conclusions: An accurate and relevant staging system for patients with HCC was derived though modification of the BCLC system based on PS.

Keywords: Barcelona Clinic Liver Cancer Staging; Eastern Cooperative Oncology Group performance status; Hepatocellular carcinoma; Stage.

Conflict of interest statement

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

Figures

Fig. 1
Fig. 1
Comparison of overall survival (OS) according to Barcelona Clinic Liver Cancer (BCLC) stage, modified Union for International Cancer Control (UICC), and performance status (PS) in all patients. (A) Comparison of OS according to BCLC. (B) Comparison of OS according to modified UICC. (C) Comparison of OS according to PS in all patients.
Fig. 2
Fig. 2
Comparison of overall survival (OS) according to performance status (PS). (A) Comparison of OS according to performance status (PS) in original Barcelona Clinic Liver Cancer (BCLC) stage C. (B) Comparison of OS according to PS in the modified BCLC #2 model stage C.
Fig. 3
Fig. 3
Proposal for modification of Barcelona Clinic Liver Cancer (BCLC) system. (A) Original BCLC system. (B) Modified BCLC #1 model. (C) Modified BCLC #2 model. (D) Modified BCLC #3 model. CPC, Child-Pugh class; PS, performance status.
Fig. 4
Fig. 4
Comparison of overall survival (OS) according to stage in the modified Barcelona Clinic Liver Cancer (BCLC) models. (A) Comparison of OS according to stage in the modified BCLC #1. (B) Comparison of OS according to stage in the modified BCLC #2. (C) Comparison of OS according to stage in the modified BCLC #3.
Fig. 5
Fig. 5
Comparison of integrated area under the curve (IAUC) between the original and modified Barcelona Clinic Liver Cancer (BCLC) systems. CI, confidence interval.
Fig. 6
Fig. 6
Proposal for subclassification of stage C in the modified Barcelona Clinic Liver Cancer (BCLC) #2 system. (A) Diagram of the proposed subclassification of stage C in the modified BCLC #2 system. (B) Comparison of the overall survival (OS) according to the subclassification of stage C in the modified BCLC #2 system. CPC, Child-Pugh class; PS, performance status; CPS, Child-Pugh score; EHS, extrahepatic spread: VI, vascular invasion.

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