Keywords
We read with great interest the article by Reig and colleagues presenting the 2022 update of one of the most used staging systems for hepatocellular carcinoma (HCC), the Barcelona Clinic Liver Cancer (BCLC) staging system.
[1]
The current version is improved over its predecessor, with further stratification of the heterogenous BCLC-B group, the addition of newer immunotherapy options for the BCLC-C group and consideration of liver transplant (LT) as an option for those with tumor burden acceptable for transplant regardless of their liver dysfunction. However, there remains a lot to be desired, especially regarding the use of liver function in BCLC stage allocation and linking the first treatment option to be considered with the current system.fdb 9.1.450/W UnicodeThe suggested classification recommends classifying a patient’s liver function into two dichotomous classes, “preserved liver function” and “end-stage liver function” for stage allocation and prognosis. Patients with decompensation in the form of jaundice, ascites, and hepatic encephalopathy (HE) are labeled as having “non-preserved liver function” and those with compensated cirrhosis are further classified based on their albumin-bilirubin (ALBI) score.
[2]
Hence the use of the dichotomous classification of patients with HCC based on liver function potentially prevents patients with any decompensation from being classified into BCLC stage 0, A, B, or C; even though a subgroup might have tumor burden and tumor-related symptoms concordant with these stages, and might derive benefit from coupled stage-appropriate treatment options. Patients with HCC often present late during their course of liver disease, and almost 50% are Child-Pugh status B or C and have some decompensation, such a classification will potentially prevent a significant fraction of patients from receiving stage-appropriate therapies.[3]
Moreover, in areas with predominant hepatitis B related HCC, adequate antiviral treatment has not only been shown to prevent recurrence but also improve liver function so that a number of patients on antiviral therapy become eligible for curative treatment.[4]
,[5]
At the other end of the spectrum are those patients labeled as “end-stage liver function” and classified as BCLC-D and linked to supportive care. However, the term “end-stage liver function” is not well defined as often used synonymously with “liver failure” or “decompensation”.
[6]
In stark contrast to other terminal illnesses, LT is a viable treatment option for patients with end-stage liver function. Moreover, even patients with decompensation are heterogeneous depending on the quantification of their decompensation, viz patients with minimal HE or mild ascites have a better prognosis than those with overt HE or tense ascites.Walling AM, Wenger N.Palliative care for patients with end-stage liver disease - UpToDate [Internet]. [cited 2021 Nov 30]. Available from: https://www.uptodate.com/contents/palliative-care-for-patients-with-end-stage-liver-disease.
[7]
Hence, the use of a dichotomous classification might not serve the purpose of stage allocation and be subject to misinterpretation and consequent misclassification of patients. We do agree with the authors that treatment decisions for patients with HCC are often complex and should take into account multiple dimensions and not just a single variable, but the appeal of such staging systems lies in their unambiguity, so that they are not open to more than one interpretation.[1]
Financial support
The authors received no financial support to produce this manuscript.
Authors’ contributions
Anshuman Elhence- Manuscript writing, revision, and concept.
Shalimar- Manuscript writing, revision, and concept.
Conflict of interest
The authors declare no conflicts of interest that pertain to this work.
Please refer to the accompanying ICMJE disclosure forms for further details.
Supplementary data
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References
- BCLC strategy for prognosis prediction and treatment recommendation: The 2022 update.J Hepatol. 2022; 76: 681-693
- Assessment of liver function in patients with hepatocellular carcinoma: a new evidence-based approach—the ALBI grade.J Clin Oncol. 2015 Feb 20; 33: 550-558
- Clinical profile, etiology and therapeutic outcome in 324 hepatocellular carcinoma patients at a tertiary care center in India.Oncology. 2009; 77: 162-171
- Efficacy of antiviral therapy with lamivudine after initial treatment for hepatitis B virus-related hepatocellular carcinoma.J Gastroenterol Hepatol. 2007 Nov; 22: 1929-1935
- A comparative study of antiviral therapy after resection of hepatocellular carcinoma in the immune-active phase of hepatitis B virus infection.Ann Surg Oncol. 2010 Jan; 17: 179-185
Walling AM, Wenger N.Palliative care for patients with end-stage liver disease - UpToDate [Internet]. [cited 2021 Nov 30]. Available from: https://www.uptodate.com/contents/palliative-care-for-patients-with-end-stage-liver-disease.
- Hepatic encephalopathy is associated with mortality in patients with cirrhosis independent of other extrahepatic organ failures.Clin Gastroenterol Hepatol. 2017 Apr; 15: 565-574.e4
Article info
Publication history
Published online: December 23, 2021
Accepted:
December 17,
2021
Received in revised form:
December 9,
2021
Received:
December 1,
2021
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Copyright
© 2021 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.
