The Japanese integrated staging score using liver damage grade for hepatocellular carcinoma in patients after hepatectomy

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Abstract

Aims. The new Japanese staging system for hepatocellular carcinoma (HCC), the Japan integrated staging (JIS) score, accounts for both Child–Pugh classification and Japan tumour node metastasis (TNM) staging. However, in HCC patients who undergo hepatectomy, liver function is relatively good and a better prognostic classification of hepatic function is necessary.

Methods. The present study was designed to analyse the modified JIS score using liver damage grade by the Liver Cancer Study Group of Japan instead of the Child–Pugh classification (using the category indocyanine green retention rate at 15 min [ICGR15] instead of encephalopathy), and to compare the Japan TNM stage in 101 patients who underwent resection of HCC.

Results. The liver damage grade showed significantly better discrimination of disease-free and overall survival than did the Child–Pugh classification. The modified JIS score system showed significant differences of disease-free and overall survivals in each score and this system was superior for discriminating survivals compared with the TNM staging.

Conclusions. The combined staging system of hepatic function, particularly ICGR15, and tumour stage provides a better prediction of prognosis. The JIS score using the liver damage grade was a useful predictor of prognosis of HCC patients who underwent hepatic resection.

Introduction

Hepatic resection is a good option for radical treatment of hepatocellular carcinoma (HCC)1., 2. and prognosis of patients that undergo such treatment correlates with several tumour-associated factors and liver function.3., 4. The tumour node metastasis (TNM) staging proposed by the Union Internationale Contre le Cancer (International Union against Cancer: UICC)5 and the Liver Cancer Study Group of Japan6 were the useful staging systems of tumour factors. Okamoto has reported the first combined-staging system of both tumour stage and liver function.7 Recently, new combined-staging systems using tumour and liver function factors such as the Cancer of the Liver Italian Program (CLIP),8., 9., 10. Barcelona Clinic Liver Cancer (BCLC),11 Japan integrated staging (JIS) score,12 Chinese University Prognostic Index (CUPI)13 have been proposed and the clinical usefulness of these staging systems for predicting prognosis of patients with HCC were clarified. The JIS score comprising a combination of the Japanese TNM staging and the Child–Pugh classification, which was proposed by the Liver Cancer Study Group of Japan, was the best discriminating staging when compared with TNM staging and CLIP score in 722 Japanese HCC patients.12 The Child–Pugh classification has been commonly used for evaluation in patients with chronic liver diseases.14 This classification may enhance survival of patients with HCC. The liver damage grade proposed by the Liver Cancer Study Group of Japan is also a useful classification for hepatic function6 and those patients with poor liver damage grade compared to the Child–Pugh grade. In HCC patients who undergo hepatic resection, liver function is relatively good and the majority of patients had Child–Pugh A disease. Therefore, it is unclear whether the original JIS score is useful in these patients after hepatectomy.

Patients with poor liver function may die from liver failure, or the severity of liver damage may be associated with the biological behaviour of HCC. We hypothesized that a staging system that uses a reliable classification of hepatic function and tumour stage would provide a better prediction of prognosis of HCC patients than existing systems. In the present study, we conducted a retrospective preliminary analysis of 101 Japanese patients with HCC after hepatic resection at a single Japanese cancer unit. We examined the clinical usefulness of survival as predicted by the JIS system modified using the liver damage grade in these HCC patients, and compared the results with that of the Japanese TNM stage.

Section snippets

Patients

Data from 101 patients with HCC were collected during surgery on patients who were admitted to the Division of Surgical Oncology, Department of Translational Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences (NUGSBS) and its associated hospitals between January 1990 and January 2003. Patients with remnant tumour after hepatectomy were excluded from this study. The mean age of the patients at the time of surgery was 62.8±9.4 years (range, 28–81 years), and they

Disease-free survival after hepatic resection

In the present study, 61 patients developed tumour recurrence after hepatectomy. Among 101 patients in the study, the disease-free 1-, 3- and 5-year survival rates were 66, 43 and 33%, respectively, and the median disease-free survival period was 3.7 years. Fig. 1(A) shows the disease-free survival curves according to classifications for liver function. Discrimination of the long-term survival in the liver damage grade appeared to perform better than the Child–Pugh classification. Fig. 1(B)

Discussion

The TNM staging of the Liver Cancer Study Group of Japan is useful for determining the spread of HCC,6 and has been commonly used in Japan.15 Recently, Ueno et al.10 reported the clinical usefulness of the CLIP score in a large number of Japanese HCC patients and, therefore, a combined staging system comprising both tumour factors and liver function has been noted in HCC patients since the system reported by Okamoto7 Furthermore, Kudo et al.12 reported that the JIS score combined with the

Acknowledgements

We are grateful to the Digestive System Group of the Second Department of Internal Medicine, Nagasaki University School of Medicine (Prof. Kohno and Dr Omagari), and the Department of Internal Medicine, Nagasaki Municipal Medical Center (Dr Yamasaki) and other associated hospitals for the diagnosis, comments and follow-up of patients with HCC who underwent surgical treatment at our institution.

References (21)

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