Comparative Study of Staging Systems for Hepatocellular Carcinoma in 428 Patients Treated with Radioembolization

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To compare the utility of different staging systems and analyze independent predictors of survival in patients with hepatocellular carcinoma (HCC) treated with yttrium-90 (90Y) radioembolization.

Materials and Methods:

During the period 2004–2011, 428 patients with HCC were treated with 90Y radioembolization. All patients were staged prospectively by the following staging systems: Child-Turcotte-Pugh (CTP), United Network for Organ Sharing, Barcelona Clinic Liver Cancer (BCLC), Okuda classification, Cancer of the Liver Italian Program (CLIP), Groupe d'Etude et de Traitement du Carcinome Hepatocellulaire, Chinese University Prognostic Index, and Japan Integrated Staging. The ability of the staging systems to predict survival was assessed. The staging systems were compared using Cox proportional hazards regression model, linear regression, Akaike information criterion (AIC), and concordance index (C-index). Univariate and multivariate analyses were employed to assess independent predictors of survival.


When tested independently, all staging systems exhibited significant ability to discriminate early (long survival) from advanced (worse survival) disease. CLIP provided the most accurate information in predicting survival outcomes (AIC = 2,993, C-index = 0.8503); CTP was least informative (AIC = 3,074, C-index = 0.6445). Independent predictors of survival included Eastern Cooperative Oncology Group performance status grade 0 (hazard ration [HR], 0.56; confidence interval [CI], 0.34–0.93), noninfiltrative tumors (HR, 0.62; CI, 0.44–0.89), absence of portal venous thrombosis (HR, 0.60; CI, 0.40–0.89), absence of ascites (HR, 0.56; CI, 0.40–0.76), albumin ≥ 2.8 g/dL (HR, 0.72; CI, 0.55–0.94), alkaline phosphatase ≤ 200 U/L (HR, 0.68; CI, 0.50–0.92), and α-fetoprotein ≤ 200 ng/mL (HR, 0.67; CI, 0.51–0.86).


CLIP was most accurate in predicting survival in patients with HCC. Given that not all patients receive the recommended BCLC treatment strategy, this information is relevant for clinical trial design and predicting long-term outcomes after 90Y radioembolization.

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