Evaluation of predictive value of CLIP, Okuda, TNM and JIS staging systems for hepatocellular carcinoma patients undergoing surgery

BACKGROUND: An accurate staging system is required to assess hepatocellular carcinoma (HCC) patients in order to benefit from hepatic resection before surgery. Cancer of the Liver Italian Program (CLIP) score was considered to be better than the Okuda staging system to predict survival. Japan Integrated Staging Score (JIS score) includes tumor, nodes, metastases (TNM) stage and Child-Pugh grade as a new staging system for HCC. The purpose of the present paper was to compare the CLIP, Okuda, TNM and JIS staging systems for HCC patients undergoing surgery. METHODS: From 1991 to 1995, 599 patients undergoing hepatic resection for HCC from four medical centers in Taiwan were evaluated. All patients were classified by Okuda, CLIP, TNM and JIS systems. Factors associated survivals were analyzed. RESULTS: There was no statistical difference in survival between CLIP 0 and 1 patients, or among CLIP 2-4 patients. The prognostic validation of the Okuda and CLIP scoring systems in discriminating survival in HCC patients undergoing surgery was not satisfied. The TNM system was successful in predicting survival for HCC patients undergoing surgery. The JIS score could also differentiate survivals for those patients except for JIS 3. By multivariate analysis, age > or =60 years old, serum albumin <3.5 g/dL, tumor size >5 cm and TNM stage were associated with survival. CONCLUSION: Both the Okuda and CLIP systems are not superior to TNM staging for HCC patients who undergo surgical resection. Whether JIS score is feasible for those patients with advanced HCC needs further evaluation.     

Prognostic factors for survival in patients with hepatocellular carcinoma after radiofrequency ablation]

BACKGROUND/AIMS: Currently there is no consensus on which staging system is the best in predicting the survival of patients with hepatocellular carcinoma (HCC). The aim of this study was to identify independent factors to predict survival and to compare 4 available prognostic staging systems in patients with early HCC after radiofrequency ablation. METHODS: We retrospectively studied 100 Korean patients with early HCC. Prognostic factors for survival were analysed by univariate and multivariate analysis using the Kaplan-Meier method and Cox proportional hazard regression models. Okuda, Cancer of the Liver Italian Program (CLIP), TNM and Japanese integrated staging score (JIS score) were evaluated before the treatments. RESULTS: Overall survival rates of 12, 24 and 36 months were 89%, 76%, and 64% respectively and the mean survival duration was 45 months. Multivariable analysis showed that albumin, total bilirubin and size of tumor were independent prognostic factors. Multivariate analysis showed that TNM and JIS score staging systems were significant staging systems for the prediction of prognosis. CONCLUSIONS: Both TNM and JIS score are more effective than the Okuda and CLIP staging systems in stratifying patients into different risk groups with early HCC. However, JIS score gives better prediction of prognosis in patients with HCC after radiofrequency ablation.     

Comparison of four current staging systems for Chinese patients with hepatocellular carcinoma undergoing curative resection: Okuda, CLIP, TNM and CUPI

Background and Aim: Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide. However, there is no general consensus as to which staging system is the most reliable for predicting the survival of patients with HCC. The aims of this study were to compare commonly‐used staging systems in a cohort of Chinese HCC patients undergoing curative resection. Methods: From January 1991 to June 2002, 234 Chinese patients undergoing curative resection for HCC from one medical center were evaluated. All patients were classified by the Okuda, Cancer of the Liver Italian Program (CLIP), tumor node metastasis (TNM) (6th edition) and the Chinese University Prognostic Index (CUPI) staging systems. Survival curves were calculated using the Kaplan–Meier method and were examined using log‐rank testing. The overall predictive power for patient survival with each staging system was evaluated by the area under the receiver operating characteristic (ROC) curve. Results: The overall median survival of the entire cohort was 24.9 months (95% confidence interval (CI) 18.15–31.65 months) and the estimated survival rates at 1, 3, and 5 years were 69.66% ± 3.01%, 41.02% ± 3.31%, and 29.08% ± 3.55%, respectively. In our patient cohort, the log‐rank test demonstrated that the TNM and Okuda staging systems gave better results than the other staging systems in the prognosis stratification. The prognostic predictive powers of the TNM staging for survival, evaluated by ROC curve areas, was also superior. Conclusions: For HCC patients undergoing curative resection, the TNM staging system (6th edition) proved the best for prognostic stratification and prognosis prediction.     

Comparative performances of staging systems for early hepatocellular carcinoma

Background:

Several staging systems for patients with hepatocellular carcinoma (HCC) have been proposed, but studies of their prognostic accuracy have yielded conflicting conclusions. Stratifying patients with early HCC is of particular interest because these patients may derive the greatest benefit from intervention, yet no studies have evaluated the comparative performances of staging systems in patients with early HCC.

Methods:

A retrospective cohort study was performed using data on 379 patients who underwent liver resection or liver transplantation for HCC at six major hepatobiliary centres in the USA and Europe. The staging systems evaluated were: the Okuda staging system, the International Hepato-Pancreato-Biliary Association (IHPBA) staging system, the Cancer of the Liver Italian Programme (CLIP) score, the Barcelona Clinic Liver Cancer (BCLC) staging system, the Japanese Integrated Staging (JIS) score and the American Joint Committee on Cancer/International Union Against Cancer (AJCC/UICC) staging system, 6th edition. A recently proposed early HCC prognostic score was also evaluated. The discriminative abilities of the staging systems were evaluated using Cox proportional hazards models and the bootstrap-corrected concordance index (c).

Results:

Overall survival of the cohort was 74% at 3 years and 52% at 5 years, with a median survival of 62 months. Most systems demonstrated poor discriminatory ability (P > 0.05 on Cox proportional hazards analysis, c≈ 0.5). However, the AJCC/UICC system clearly stratified patients (P < 0.001, c= 0.59), albeit only into two groups. The early HCC prognostic score also clearly stratified patients (P < 0.001, c= 0.60) and identified three distinct prognostic groups.

Discussion:

The early HCC prognostic score is superior to the AJCC/UICC staging system (6th edition) for predicting the survival of patients with early HCC after liver resection or liver transplantation. Other major HCC staging systems perform poorly in patients with early HCC.     

Comparison of seven prognostic staging systems in patients who undergo hepatectomy for hepatocellular carcinoma

BACKGROUND/AIMS: Various staging systems containing both the tumor and liver function factors for hepatocellular carcinoma (HCC) have been proposed. The aim of this study was to evaluate the appropriate staging system in patients received hepatic resection for HCC. METHODOLOGY: The prognosis of the 235 patients who had undergone hepatectomy in these 15 years were analyzed according to the 7 staging systems, the Cancer of the Liver Italian Program (CLIP) score, the Barcelona Clinic Liver Cancer (BCLC) staging, the Groupe d'Etude et de Traitment du Carcinome Hépatocellulaire (GETCH) classification, the Chinese University Prognostic Index (CUPI) grade, the Japan Integrated Staging (JIS) score, modified JIS (mJIS) score, and Tokyo score. The capabilities to differentiate the postoperative survival between the neighboring score in each staging system were examined. Statistical analyses of the log-rank test, linear trend test, likelihood ratio (LR) test, Akaike Information Criteria (AIC), and Harrels' c-index were used. RESULTS: The patients were widely distributed in the most of the staging system with the exceptions of GETCH classification and CUPI grade where almost all patients were classified to only the two groups. CLIP, JIS, mJIS, and Tokyo scores significantly differentiated the postoperative survival rate between 2 or 3 neighboring scores, whereas other staging systems only did between one. Statistical evaluations of prognostic stratification by the LR test, AIC, and Harrels' c-index showed that the JIS score system was the best among the 7 staging systems. CONCLUSIONS: JIS score is the best staging system for HCC in patients who undergo hepatectomy.     

Comparison of the usefulness of three staging systems for hepatocellular carcinoma (CLIP, BCLC, and JIS) in Japan

OBJECTIVES: We retrospectively compared the usefulness of three different staging systems for hepatocellular carcinoma (HCC), the Cancer of the Liver Italian Program (CLIP) scoring system, the Barcelona Clinic Liver Cancer (BCLC) classification system, and the Japan Integrated Staging (JIS) system, in terms of patient distribution and survival rates. METHODS: Subjects were 1,508 patients diagnosed as having initial HCC during the period of 1976-2003. The disease was staged in all patients by means of the three staging systems, and the distribution of patients across stages and associated survival rates were compared between systems. In addition, comparisons were made on the basis of the time of diagnosis: 1976-1990 (n = 497) and 1991-2003 (n = 1,011). RESULTS: Patients were evenly distributed across stages within each staging system, and survival rates differed between stages except for BCLC C and D. During the period 1991-2003, when HCCs were smaller at diagnosis, JIS system is in particular yielded even distribution of patient across stages and marked differences in survival rates. CONCLUSIONS: Overall, the CLIP and the JIS scoring systems proved to be suitable for patients in Japan with HCC. The CLIP staging systems proved to be more suitable before 1991. In contrast, the JIS system was the most suitable after 1990, when early detection and early treatment of HCC became common. The JIS system is, therefore, the appropriate system in this era of early detection and treatment of HCC.     

Prognosis of hepatocellular carcinoma in anti-HCV positive cirrhotic patients: a single-centre comparison amongst four different staging systems

BACKGROUND: Epidemiological studies have foreseen an increase in the incidence of hepatocellular carcinoma (HCC) in the near future and it is estimated that this trend will mostly affect hepatitis C virus (HCV) positive cirrhotic patients. Therefore, accuracy of HCC staging is an important clinical issue. AIM: To investigate the prognostic usefulness of a series of newly proposed HCC prognostic systems such as the Cancer of the Liver Italian Program (CLIP) score, the Groupe d'Etude et de Traitement du Carcinome Hépatocellulaire (GRETCH) model and the Barcelona Clinic Liver Cancer (BCLC) staging classification when compared with the usefulness of a known staging system such as the Okuda staging system in a group of anti-HCV positive cirrhotic patients with HCC seen at a single centre. METHODS: Okuda stage, CLIP score, GRETCH model and BCLC stages were retrospectively computed in 81 anti-HCV positive cirrhotic patients with HCC. We evaluated and compared the ability of these methods to assess survival prognosis. RESULTS: As of December 2001, 51 patients had died and overall median survival was 18 months. All the staging systems were able to identify various patient subgroups with different survival. The CLIP score, the GRETCH model and the BCLC staging classification were better at characterizing the 1-year prognosis of the patients when compared with the Okuda staging system, whilst the 3-year prognostic evaluation was improved only by using the CLIP score or the BCLC staging classification. CONCLUSIONS: The prognostic value and usefulness of the CLIP score, the GRETCH model and the BCLC staging classification was reproduced in a single-centre analysis of anti-HCV positive HCC cirrhotic patients. These scores provided a prognostic assessment of our patients which is superior to what was obtained by the Okuda staging system.     

Staging hepatocellular carcinoma by a novel scoring system (BALAD score) based on serum markers.

BACKGROUND & AIMS: Previously proposed staging systems for hepatocellular carcinoma (HCC) involve clinical, imaging, or pathologic factors in the evaluation. We established and validated a novel staging system for HCC that is based on simply serum markers. METHODS: The new scoring system is based on 5 serum markers: bilirubin, albumin, Lens culinaris agglutinin-reactive alpha-fetoprotein (AFP-L3), alpha-fetoprotein (AFP), and des-gamma-carboxy prothrombin (DCP) and thus is termed the BALAD score. The system was validated in 2600 HCC patients from 5 institutions. The power of our system to predict patient survival and its discriminative ability were compared with those of previously reported staging systems. RESULTS: The best tumor marker cutoff values were 400 ng/dL for AFP, 15% for AFP-L3, and 100 milli-arbitrary unit/mL for DCP. The patients were classified into 6 categories on the basis of 5 laboratory values. The categories reflected patient survival well. The discriminative ability was comparable to that of previously reported staging systems. CONCLUSIONS: The new staging system for HCC combining serum albumin, serum bilirubin, and 3 tumor markers predicts patient outcomes with excellent discriminative ability. The system is easy to use and objective. In addition, stage can be evaluated with the use of only 1 serum sample. It also allows global comparison of patients with HCC or comparison of patients from different time periods with the same standard.     

Comparison of seven staging systems in cirrhotic patients with hepatocellular carcinoma in a cohort of patients who underwent radiofrequency ablation with complete response

BACKGROUND AND AIMS: Many staging systems for hepatocellular carcinoma (HCC) have been proposed but the best tool for staging of HCC remains controversial. The aim of the present study was to identify the best staging system evaluating the predictive ability for outcome for each of the seven different staging systems applied in a homogeneous group of patients who underwent percutaneous radiofrequency ablation (RFA). METHODS: We analyzed retrospectively 112 patients with HCC and cirrhosis treated with percutaneous RFA from January, 1998 to April, 2005. Response to treatment after 30 days and for long-term follow-up was evaluated with computed tomography (CT) or magnetic resonance imaging (MRI) and serum alpha-fetoprotein level (AFP). All of the 112 patients were grouped according to each one of the seven different staging systems: Okuda, TNM, BCLC, CLIP, GRETCH, CUPI, JIS. RESULTS: The mean follow-up time of the 112 patients submitted to RFA was 24 months (range 3-92 months) with survival rates at 1, 3, and 5 yr of 82%, 40%, and 18%, respectively. Univariate and multivariate analyses showed that factors related to survival were Child-Pugh score (P相似文献   

Comparison of three current staging systems for hepatocellular carcinoma: Japan integrated staging score, new Barcelona Clinic Liver Cancer staging classification, and Tokyo score

Background and Aim: Although various staging systems for hepatocellular carcinoma (HCC) have been developed in recent years, there is no worldwide consensus which staging system is best. The aim of the present study was to compare the performance of the currently developed three staging systems: the Japan integrated staging (JIS) score, new Barcelona Clinic Liver Cancer (BCLC) staging classification, and the Tokyo score. Methods: A total of 290 consecutive patients with HCC before initial treatment at Kinki University between January 1999 and December 2001 were included. The patients were stratified according to the three staging systems, and the performance of the staging systems was compared using survival time as the only outcome measure. Results: There were significant differences between all stages in the JIS score, while no significant difference was found between stages C and D in the BCLC staging classification and between all the scores, except between scores 0 and 1 and 2 and 3 in the Tokyo score. For all patients (n = 290), the radical treatment group (n = 208) and the non‐radical treatment group (n = 82), the likelihood ratio χ²‐test showed the highest value, and the Akaike information criterion value was lowest in the JIS score. Conclusion: The JIS score provided the best prognostic stratification in a Japanese cohort of HCC patients who were mainly diagnosed at early stages and treated with radical therapies.     

Portal hypertension predicts short-term and long-term outcomes after hepatectomy in hepatocellular carcinoma patients

Background and aims: The impact of portal hypertension (PH) on postoperative short-term outcomes and long-term survival in hepatocellular carcinoma (HCC) patients has lately been discussed controversially. This study aimed to explore the influence of PH on postoperative outcomes in HCC patients undergoing surgical resection.

Methods: Patients undergoing hepatectomy for HCC from 2010 to 2014 were enrolled. The impact of PH on postoperative complications, posthepatectomy liver failure (PHLF) and overall survival (OS) was evaluated.

Results: A total of 355 HCC patients were enrolled; 129 (36.3%) experienced postoperative complications and 21 (5.9%) developed PHLF. PH was identified as an independent predictor of PHLF. Patients with PH experienced a higher incidence of complications and PHLF than patients without PH. On the Cox proportional hazards regression model, PH was verified as a risk factor of OS for BCLC stage 0/A and B patients. Patients without PH had significantly better long-term survival compared to patients with PH both in the total cohort and in cirrhosis subgroup.

Conclusion: Liver resection in HCC patients with PH showed a significantly increased postoperative complications and PHLF, and revealed a decreasing long-term survival than non-PH patients. Besides, tumor burden also played an important role in determining the OS. However, due to the improvement in surgical technique and perioperative management, surgery was feasible in carefully selected HCC patients with PH.     

Do the existing staging systems for primary liver cancer apply to combined hepatocellular carcinoma-intrahepatic cholangiocarcinoma?

Background:The incidence of combined hepatocellular carcinoma-intrahepatic cholangiocarcinoma(c HCC-ICC) is relatively low,and the knowledge about the prognosis of c HCC-ICC remains obscure.In the study,we aimed to screen existing primary liver cancer staging systems and shed light on the prognosis and risk factors for c HCC-ICC.Methods:We retrospectively reviewed 206 c HCC-ICC patients who received curative surgical resection from April 1999 to March 2017.The correlation of survival measures with the histological types or with tumor staging systems was determined and predictive values of tumor staging systems with c HCC-ICC prognosis were compared.Results:The histological type was not associated with overall survival(OS)(P = 0.338) or disease-free survival(DFS)(P = 0.843) of patients after curative surgical resection.BCLC,TNM for HCC,and TNM for ICC stages correlated with both OS and DFS in c HCC-ICC(all P 0.05).The predictive values of TNM for HCC and TNM for ICC stages were similar in terms of predicting postoperative OS(P = 0.798) and DFS(P = 0.191) in c HCC-ICC.TNM for HCC was superior to BCLC for predicting postoperative OS(P = 0.022) in c HCC-ICC.Conclusion:The TNM for HCC staging system should be prioritized for clinical applications in predicting c HCC-ICC prognosis.     

Prospective validation of the Eastern Staging in predicting survival after surgical resection for patients with hepatocellular carcinoma: a multicenter study from China

BackgroundThe Eastern Staging System, which was specially developed for patients undergoing surgical resection for hepatocellular carcinoma (HCC), has been proposed for more than ten years. To prospectively validate the predictive accuracy of the Eastern staging on long-term survival after HCC resection.MethodsPatients who underwent hepatectomy for HCC from 2011 to 2020 at 10 Chinese hospitals were identified from a prospectively collected database. The survival predictive accuracy was evaluated and compared between the Eastern Staging with six other staging systems, including the JIS, BCLC, Okuda, CLIP, 8th AJCC TNM, and HKLC staging.ResultsAmong 2365 patients, the 1-, 3-, and 5-year overall survival rates were 84.2%, 64.5%, and 52.6%, respectively. Among these seven staging systems, the Eastern staging was associated with the best monotonicity of gradients (linear trend χ²: 408.5) and homogeneity (likelihood ratio χ²: 447.3), and the highest discriminatory ability (the areas under curves for 1-, 3-, and 5-year mortality: 0.776, 0.787, and 0.768, respectively). In addition, the Eastern staging was the most informative staging system in predicting survival (Akaike information criterion: 2982.33).ConclusionUsing a large multicenter prospectively collected database, the Eastern Staging was found to show the best predictive accuracy on long-term overall survival in patients with resectable HCC than the other 6 commonly-used staging systems.     

Staging of hepatocellular carcinoma

Clinical staging systems for hepatocellular carcinoma (HCC) provide guides to patient assessment and therapeutic decision making. The most commonly used staging systems for HCC internationally are the Okuda classification and the pathologic tumor node metastasis (TNM) classification. But each has its own limitations. New staging systems for HCC have recently been reported from Italy, France, Spain and China. In this review, we evaluated the staging systems of HCC and discussed the natural history and prognosis of tumors of different stages. We believe that a reliable new staging system of HCC patients will be established in the near future.     

A new staging system for resectable hepatocellular carcinoma: comparison with six existing staging systems in a large Chinese cohort

Purpose  

Surgical resection remains the gold standard for hepatocellular carcinoma (HCC). Although various staging systems have been developed in recent years, the best tool for staging of HCC remains controversial. The aims of this study were to establish a new staging for patients with HCC undergoing surgical resection and to indentify whether this staging is superior to other staging systems in predicting survival of resectable HCC.     

肝细胞癌四种临床分期系统预后判断和治疗指导价值的比较

目的 比较4个分期系统[巴塞罗那临床肝癌分期标准(BCLC)、日本综合分期积分(JIS)、意大利肝癌评分(CLIP)和国内分期]对中国肝癌患者预后判断和对治疗方案选择的指导意义.方法 回顾性分析2001年至2002年复旦大学附属中山医院收治的861例初发肝细胞癌患者的临床资料,分别按4个分期系统分期或评分,比较各期患者的生存情况以及不同治疗方案对其生存的影响.结果 在判断预后方面,BCLC、JIS和国内分期系统的各分期间生存率差异均有统计学意义;而在CLIP分期的一些评分间的生存率差异无统计学意义.在指导治疗方面,BCLC C期,CLIP 3、4分以及国内分期ⅢA期的患者接受手术治疗与接受肝动脉化学治疗栓塞(TACE)和(或)肝动脉栓塞(TAE)治疗的生存率差异无统计学意义;而比这些更早期的患者接受手术治疗的生存率优于接受TACE和(或)TAE治疗的生存率.结论 BCLC、JIS和国内分期系统在判断预后方面适用于中国患者;但仅国内分期和BCLC分期同时兼备了判断预后和指导治疗两方面的作用.     

Review of current staging systems for hepatocellular carcinoma

Several staging systems have been developed to classify patients with hepatocellular carcinoma (HCC), however, there is no consensus on which of these is the most useful and reliable. In this review article, currently available integrated staging systems taking into account both liver function and tumor progression are presented, and their characteristics and applicability for current HCC patients, many of whom are diagnosed in the early stage of the disease and treated by curative therapy, are discussed. Based on the original andsubsequent validation studies of these staging systems, we recommend that further validation studies of staging systems for HCC should focus on the revised Barcelona Clinic Liver Cancer (BCLC) staging classification, Japan Integrated Staging (JIS) score and Tokyo score.     

A model to estimate survival in ambulatory patients with hepatocellular carcinoma: Can it predict the natural course of hepatocellular carcinoma?

BackgroundSeveral hepatocellular carcinoma (HCC) staging systems are available including the newly developed staging system, the Model to Estimate Survival in Ambulatory HCC patients (MESIAH); however, whether these staging systems could predict the natural course of HCC is largely unknown.Methods1013 patients with history of HCC treatment and 111 patients without any history of treatment till death or last follow-up at a single tertiary hospital were included.ResultsThe MESIAH score showed a better discrimination ability, with a C-statistic of 0.835 [95% confidence interval (CI), 0.810–0.861] in the group of treated patients compared to the Barcelona Clinic Liver Cancer (BCLC) staging system [0.739 (95% CI, 0.709–0.769)] before propensity score matching. However, the MESIAH score failed to stratify patients according to their risk of death in the group of untreated patients unlike the BCLC staging system. Propensity score matching analysis confirmed that the MESIAH score was most strongly influenced by whether treatment was given or not.ConclusionsAlthough the MESIAH score provided better prognostic stratification than other staging systems in treated HCC patients, it was not helpful in predicting the natural course of HCC. Since the treatment affects patient outcome and prognosis, it is necessary to develop a new staging system that can also reflect the natural course of HCC.     

The critical issue of hepatocellular carcinoma prognostic classification: which is the best tool available?

BACKGROUND/AIMS: Prognosis assessment in patients with hepatocellular carcinoma (HCC) remains controversial. The most widely used HCC prognostic tool is the Okuda classification, but new staging systems (Cancer of the Liver Italian Program score, Chinese University Prognostic Index, French classification and Barcelona Clinic Liver Cancer, BCLC, staging) have been recently described. We investigated the value of known prognostic systems in the particular setting of a surgically oriented Liver Unit where 187 HCC Italian patients were mainly treated with radical therapies (resection and percutaneous ablation). METHODS: A retrospective analysis of 187 HCCs observed at a single Institution from 1990 and 1999 was performed. By using survival time as the only outcome measure (Kaplan-Meier method and Cox regression), the performance of any prognostic system was assessed according the criteria of discriminatory and stratification abilities between different stages, homogeneity of survival within each stage and additional explanatory power respect to the other classifications. RESULTS: In the particular cohort studied, BCLC proved the best HCC prognostic system. This was true for the whole study group and for the 2 subgroups of surgical and non-surgical patients. CONCLUSIONS: BCLC staging showed the best interpretation of the survival distribution in an HCC population comprising a large proportion of tumors treated with potentially radical therapies.     

Staging systems: is there a surgical staging and a medical one?

Clinical staging systems for cancer provide guidelines for patient assessments and therapeutic decisions. Furthermore, appropriate staging is essential for objective comparison between the outcomes of different treatments, including clinical trials. While the prognosis of most solid tumors is generally dependent on tumor stage at presentation, prediction of prognosis in hepatocellular carcinoma (HCC) patients is more complicated because underlying liver function also affects patient survival. The Okuda classification and the pathologic tumor–node–metastasis classification are most commonly used internationally, but each has its own limitation. Several new staging systems for HCC have recently been reported from Italy, Japan, and Spain. Most prognostic models consist of parameters reflecting tumor stage and liver function reservoir, which were selected based on analyses of large series of HCC patients. Ideally, staging systems should be applicable to any HCC patient. However, each existing staging system may have been characterized by the patient population based on which it was constructed. For practical purposes, staging systems should be simple and based on data that are easily obtainable. Consensus is yet to be achieved on the optimal staging system for HCC that assures progress in the development of novel therapies.