Retrospective Study
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Sep 28, 2016; 22(36): 8194-8202
Published online Sep 28, 2016. doi: 10.3748/wjg.v22.i36.8194
Development of a prognostic scoring system for resectable hepatocellular carcinoma
Carlo Sposito, Stefano Di Sandro, Federica Brunero, Vincenzo Buscemi, Carlo Battiston, Andrea Lauterio, Marco Bongini, Luciano De Carlis, Vincenzo Mazzaferro
Carlo Sposito, Carlo Battiston, Marco Bongini, Vincenzo Mazzaferro, Gastrointestinal Surgery and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori, University of Milan, 20133 Milan, Italy
Stefano Di Sandro, Vincenzo Buscemi, Andrea Lauterio, Luciano De Carlis, General Surgery and Organ Transplants, Ospedale Niguarda Ca’Granda, 20133 Milan, Italy
Federica Brunero, Clinical Trial Office and Biomedical Statistic, Fondazione IRCCS Istituto Nazionale Tumori, 20133 Milan, Italy
Author contributions: Sposito C drafted the manuscript and supervised the study; Di Sandro S and Brunero F analyzed the data; Buscemi V, Lauterio A and Bongini M collected the data; Battiston C, De Carlis L and Mazzaferro V revised the manuscript for important intellectual content; all authors have read and approved the final version to be published.
Institutional review board statement: This study was reviewed and approved by the Ethics Committee of the Fondazione IRCCS Istituto Nazionale Tumori of Milan.
Informed consent statement: Patients were not required to give informed consent to the study because the analysis used anonymous clinical data that were obtained after each patient agreed to treatment by written consent.
Conflict-of-interest statement: No conflicts of interest are declared by the authors with respect to the material and methodology presented in the manuscript.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author at vincenzo.mazzaferro@istitutotumori.mi.it. Consent for data sharing was not obtained from participants, but the presented data are anonymised, and risk of identification is absent.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Vincenzo Mazzaferro, MD, PhD, Gastrointestinal Surgery and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori, University of Milan, Via Venezian 1, 20133 Milan, Italy. vincenzo.mazzaferro@istitutotumori.mi.it
Telephone: +39-2-23902760 Fax: +39-2-23903259
Received: May 27, 2016
Peer-review started: May 30, 2016
First decision: July 13, 2016
Revised: August 16, 2016
Accepted: August 30, 2016
Article in press: August 30, 2016
Published online: September 28, 2016
Processing time: 121 Days and 9.6 Hours
Abstract
AIM

To develop a prognostic scoring system for overall survival (OS) of patients undergoing liver resection (LR) for hepatocellular carcinoma (HCC).

METHODS

Consecutive patients who underwent curative LR for HCC between 2000 and 2013 were identified. The series was randomly divided into a training and a validation set. A multivariable Cox model for OS was fitted to the training set. The beta coefficients derived from the Cox model were used to define a prognostic scoring system for OS. The survival stratification was then tested, and the prognostic scoring system was compared with the European Association for the Study of the Liver (EASL)/American Association for the Study of Liver Diseases (AASLD) surgical criteria by means of Harrell’s C statistics.

RESULTS

A total of 917 patients were considered. Five variables independently correlated with post-LR survival: Model for End-stage Liver Disease score, hepatitis C virus infection, number of nodules, largest diameter and vascular invasion. Three risk classes were identified, and OS for the three risk classes was significantly different both in the training (P < 0.0001) and the validation set (P = 0.0002). Overall, 69.4% of patients were in the low-risk class, whereas only 37.8% were eligible to surgery according to EASL/AASLD. Survival of patients in the low-risk class was not significantly different compared with surgical indication for EASL/AASLD guidelines (77.2 mo vs 82.5 mo respectively, P = 0.22). Comparison of Harrell’s C statistics revealed no significant difference in predictive power between the two systems (-0.00999, P = 0.667).

CONCLUSION

This study established a new prognostic scoring system that may stratify HCC patients suitable for surgery, expanding surgical eligibility with respect to EASL/AASLD criteria with no harm on survival.

Keywords: Hepatocellular carcinoma; Liver resection; Liver cirrhosis; Prognosis; Survival study

Core tip: European Association for the Study of the Liver (EASL)/American Association for the Study of Liver Diseases (AASLD) guidelines recommend liver resection (LR) for hepatocellular carcinoma (HCC) only for single nodules of any size in patients without tumor related symptoms, no clinically significant portal hypertension and normal bilirubin. In this study we investigated the prognostic factors for survival of patients who underwent LR for HCC. We built a prognostic scoring system to stratify post-resection prognosis, and we identified a larger subset of patients with an expected survival that equates that of patients undergoing LR according to guidelines. Thus, the current EASL/AASLD indications for LR can be safely expanded, with no detrimental effect on patients’ prognosis.