Are Surgical Indications of Barcelona Clinic Liver Cancer Staging Classification justified?

Liver resection is the most effective treatment for hepatocellular carcinoma （HCC）. The Barcelona Clinic Liver Cancer （BCLC） staging system is commonly accepted as a guideline for HCC treatment, but it only recommends liver resection for the patients with HCC at stage 0 to A1. The surgical indications of the BCLC staging system need to be re-evaluated. 120 HCC patients undergoing curative liver resection were retrospectively stratified to the BCLC staging system, and the survival of the patients at stages A, B and C was analyzed. The justification of the BCLC staging system was re-evaluated. Fifty-two patients were classified at stage A, 51 at stage B and 17 at stage C respectively. The hospital mortality of this cohort was zero and the morbidity was 24.1%. The 1-, 2-, 3-year overall survival rate of this cohort was 81.6%, 68.3%, and 57.5% respectively. There was no signifi-cant difference in the survival rate between the patients at stage A and B （P〉0.05）. If the treatment guidelines of BCLC staging system were followed, the majority of the patients at stages A and B （77.7%, 80/103） would not have been treated surgically. Our data suggest that the surgical indications of the BCLC staging system are not justified for HCC treatment. More studies may be needed as for how to further broaden the surgical indications of the BCLC staging system in the future.

Cancer of the Liver Italian Program score helps identify potential candidates for transarterial chemoembolization in patients with Barcelona Clinic Liver Cancer stage C

BACKGROUND： The Barcelona Clinic Liver Cancer（BCLC）staging system for hepatocellular carcinoma（HCC） recommends transarterial chemoembolization（TACE） as the first line therapy for stage B patients and sorafenib treatment for stage C patients.However, stage C patients exhibit variations in terms of tumor burden, liver function, and extrahepatic metastasis, which could potentially affect disease outcome. Here, we assessed whether the Cancer of the Liver Italian Program（CLIP） scores can help identify stage C patients likely to benefit from TACE.METHODS： Out of 295 BCLC stage C HCC patients enrolled between January 2009 and December 2011, those with platelet counts 〉30×10~9 cells/L, total bilirubin 〈51 μmo L/L, and an unobstructed main portal vein were scheduled for TACE（n=195）. The remaining patients received best supportive care（BSC, n=100）.All the patients were followed up for symptoms, performance status, and Child-Pugh classification scores every 4 weeks until death or December 2013. The prognosis of each group was evaluated by using the log-rank test and Cox-Mantel test.RESULTS： The median overall survival（OS） was 6 months [95% confidence interval（CI）： 4.64-7.36]. The OS was 9 months for the TACE group and 4 months for the BSC group. The TACE group had a longer OS than the BSC subgroup for CLIP scores 0-2 [13 months（95% CI： 8.55-17.45） vs 4 months（95% CI：0.00-10.96）, P=0.001]. No significant differences were found between the TACE and BSC groups for CLIP scores 3-5. The CLIP score and treatment methods were found to be independent prognostic factors.CONCLUSIONS： BCLC stage C HCC patients exhibit definite disease heterogeneity and can be reclassified by using the CLIP scoring system. Moreover, patients with CLIP scores 0-2 are likely to benefit from TACE. However, additional studies with long-term follow-up will be required to validate these findings.

Living donor liver transplantation for Barcelona clinic liver cancer (BCLC) intermediate-stage hepatocellular carcinoma

Background:Barcelona clinic liver cancer(BCLC)stage B(intermediate stage)hepatocellular carcinoma(HCC)is highly heterogeneous;thus,identifying the most effective treatment for individual patients represents a significant clinical challenge.However,transarterial chemoembolization(TACE)is the only recommended treatment option.Therefore,we aimed to investigate the patient characteristics and outcomes of living donor liver transplantation(LDLT)for BCLC stage B HCC.Methods:A total of 516 patients with BCLC stage B HCC who underwent LDLT(n=104)or did not undergo LDLT(non-LDLT;n=412)between 2004 to 2018 were analyzed by propensity score matching(PSM;1:4)analysis.Factors influencing overall survival(OS)and recurrence were analyzed using Cox’s proportional hazards models.Results:Patients treated with LDLT achieved better OS than the non-LDLT group,including liver-and non-liver related survival(all P<0.001).Multivariate Cox regression analysis showed age>60 years(P=0.006),a neutrophil-lymphocyte ratio(NLR)>4(P=0.016)and>3 locoregional therapies(LRT)before LDLT(P<0.001)were independent risk factors for HCC recurrence.In addition,age>60 years(P<0.001)and>3 LRT before LDLT(P=0.001)were independent risk factors for OS.Using a combination of age,NLR,and LRT before liver transplantation(LT),the patients can be divided into low-risk(none of risk),intermediate-risk(one of risk),and high risk(more than two of risk)groups.There were significant differences in the cumulative HCC recurrence(P<0.001)and mortality(P<0.001)rates among the three groups.Conclusions:LDLT may represent a valuable therapeutic option for selected patients with BCLC stage B HCC.

Living donor liver transplantation can be a rescue treatment for hepatocellular carcinoma

For intermediate-stage hepatocellular carcinoma(HCC)in the Barcelona Clinic Liver Cancer(BCLC),transarterial chemoembolization(TACE)is advised as the initial treatment.The term“BCLC intermediate-stage HCC”(BCLC stage B)refers to a group of patients with varying liver functions and single big nodules or many nodules that do not have distant metastases or vascular invasion(1).In general,tumors beyond the Milan criteria(single tumor>5 cm or≥4 nodules)are classified as BCLC intermediate-stage HCC.Consequently,not every patient with intermediate-stage HCC in BCLC is a good candidate for TACE alone;this is especially true for patients who have a substantial tumor bulk,multinodular dissemination,or decreased liver function.TACE refractory cases cannot get full TACE treatment.