Currently there is no consensus which staging system is best in predicting the survival of patients with hepatocellular carcinoma (HCC). The aims of this study were to identify independent predictors of survival and to compare 7 available prognostic staging systems in patients with HCC. A total of 239 consecutive patients with cirrhosis and HCC seen between January 1, 2000, and December 31, 2003, were included. Demographic, laboratory, and tumor characteristics and performance status were determined at diagnosis and before therapy. Predictors of survival were identified using the Kaplan-Meir test and the Cox model. Sixty-two percent of patients had hepatitis C, 56% had more than 1 tumor nodule, 24% had portal vein thrombosis, and 29% did not receive any cancer treatment. At the time of censorship, 153 (63%) patients had died. The 1-and 3-year survival of the entire cohort was 58% and 29%, respectively. The independent predictors of survival were performance status (P < .0001), MELD score greater than 10 (P โซุโฌ .001), portal vein thrombosis (P โซุโฌ .0001), and tumor diameter greater than 4 cm (P โซุโฌ .001). Treatment of HCC was related to overall survival. The Barcelona Clinic Liver Cancer (BCLC) staging system had the best independent predictive power for survival when compared with the other 6 prognostic systems. In conclusion, performance status, tumor extent, liver function, and treatment were independent predictors of survival mostly in patients with cirrhosis and HCC. The BCLC staging system includes aspects of all of these elements and provided the best prognostic stratification for our cohort of patients with HCC. (HEPATOLOGY 2005;41:707-716.) H epatocellular carcinoma (HCC) is the fifth most common tumor worldwide. In the United States, the incidence of HCC has been rising, 1 and it is the tumor with the largest increase in incidence over the last 12 years. 2 Furthermore, the overall survival of patients with HCC has not improved over the last 20 years, with the incidence rate almost equal to the death rate. 3 It is projected that the increase in incidence of HCC will continue over the next 20 years in the United States. 4 Therefore, it is important to understand the factors that predict survival of patients with HCC.
Clinical staging of cancers provides a guide to assess prognosis and to direct therapeutic interventions. Welldefined, widely accepted prognostic staging systems are available for many solid tumors, including cancer of the colon 5 and prostate. 6 These staging systems have been invaluable in designing tumor surveillance programs and in comparing the efficacy of new therapies. Four key factors that may affect the prognosis of patients with HCC have been identified 7 : (1) tumor stage at diagnosis; (2) overall health of the patient; (3) hepatic synthetic function; and (4) efficacy of treatment. Several prognostic staging systems have been proposed for HCC (Table 1), [8][9][10][11][12][13][14] and recently there has been much debate regarding which prognostic staging system is the best. The lack of a consensus on an HCC staging system is in part related to the heterogeneity in diagnostic criteria of HCC when histological confirmation is not available. 7,15 Nonhisto-