Highlights
- •HCC incidence varies markedly by etiology of cirrhosis.
- •THRI is simple to use, has good predictive ability, and has been externally validated.
- •THRI may help to refine HCC surveillance guidelines for patients with cirrhosis.
Background & Aims
Current guidelines recommend biannual surveillance for hepatocellular carcinoma (HCC)
in all patients with cirrhosis, regardless of etiology. However, HCC incidence is
not well established for many causes of cirrhosis. We aimed to assess the disease-specific
incidence of HCC in a large cohort of patients with cirrhosis and to develop a scoring
system to predict HCC risk.
Methods
A derivation cohort of patients with cirrhosis diagnosed by biopsy or non-invasive
measures was identified through retrospective chart review. The disease-specific incidence
of HCC was calculated according to etiology of cirrhosis. Factors associated with
HCC were identified through multivariable Cox regression and used to develop a scoring
system to predict HCC risk. The scoring system was evaluated in an external cohort
for validation.
Results
Of 2,079 patients with cirrhosis and ≥6 months follow-up, 226 (10.8%) developed HCC. The 10-year cumulative incidence of HCC
varied by etiologic category from 22% in patients with viral hepatitis, to 16% in
those with steatohepatitis and 5% in those with autoimmune liver disease (p<0.001). By multivariable Cox regression, age, sex, etiology and platelets were associated
with HCC. Points were assigned in proportion to each hazard ratio to create the Toronto
HCC Risk Index (THRI). The 10-year cumulative HCC incidence was 3%, 10% and 32% in
the low-risk (<120 points), medium-risk (120–240) and high-risk (>240) groups respectively, values that
remained consistent after internal validation. External validation was performed on
a cohort of patients with primary biliary cirrhosis, hepatitis B viral and hepatitis
C viral cirrhosis (n = 1,144), with similar predictive ability (Harrell’s c statistic 0.77) in the validation and derivation cohorts.
Conclusion
HCC incidence varies markedly by etiology of cirrhosis. The THRI, using readily available
clinical and laboratory parameters, has good predictive ability for HCC in patients
with cirrhosis, and has been validated in an external cohort. This risk score may
help to guide recommendations regarding HCC surveillance among patients with cirrhosis.
Lay summary
HCC incidence varies markedly depending on the underlying cause of cirrhosis. Herein,
using readily available clinical and laboratory parameters we describe a risk score,
THRI, which has a good predictive ability for HCC in patients with cirrhosis, and
has been validated in an external cohort. This risk score may help to guide recommendations
regarding HCC surveillance among patients with cirrhosis.
Graphical abstract
Graphical Abstract
Keywords
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Article info
Publication history
Published online: August 24, 2017
Accepted:
July 29,
2017
Received in revised form:
July 8,
2017
Received:
July 25,
2016
Identification
Copyright
© 2017 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.
