Advertisement

Liver dysfunction in Barcelona Clinic Liver Cancer-2022 update: Clear as day or still in fog?

  • Anshuman Elhence
    Affiliations
    Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
    Search for articles by this author
  • Shalimar
    Correspondence
    Corresponding author. Address: Department of Gastroenterology, Room No 127, Human Nutrition Unit, Old OT block, AIIMS, New Delhi, India 110029.
    Affiliations
    Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
    Search for articles by this author
Published:December 23, 2021DOI:https://doi.org/10.1016/j.jhep.2021.12.016

      Keywords

      Linked Article

      • BCLC strategy for prognosis prediction and treatment recommendation: The 2022 update
        Journal of HepatologyVol. 76Issue 3
        • Preview
          There have been major advances in the armamentarium for hepatocellular carcinoma (HCC) since the last official update of the Barcelona Clinic Liver Cancer prognosis and treatment strategy published in 2018. Whilst there have been advances in all areas, we will focus on those that have led to a change in strategy and we will discuss why, despite being encouraging, data for select interventions are still too immature for them to be incorporated into an evidence-based model for clinicians and researchers.
        • Full-Text
        • PDF
      • Reply to: “Correspondence on the <BCLC strategy for prognosis prediction and treatment recommendation: The 2022 update>”
        Journal of HepatologyVol. 76Issue 5
        • Preview
          We appreciate the interest garnered by the BCLC 2022 model update. The new version has incorporated the evidence-based novelties generated in recent years, while also adding a section devoted to clinical decision making at the time of first evaluation and during a patient’s clinical evolution. No clinical practice guideline or recommendation review will ever have enough granularity to firmly recommend the most beneficial approach for an individual patient.
        • Full-Text
        • PDF
      To the Editor:
      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.
      • Reig M.
      • Forner A.
      • Rimola J.
      • Ferrer-Fábrega J.
      • Burrel M.
      • Garcia-Criado A.
      • et al.
      BCLC strategy for prognosis prediction and treatment recommendation: The 2022 update.
      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.
      • Johnson P.J.
      • Berhane S.
      • Kagebayashi C.
      • Satomura S.
      • Teng M.
      • Reeves H.L.
      • et al.
      Assessment of liver function in patients with hepatocellular carcinoma: a new evidence-based approach—the ALBI grade.
      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.
      • Paul S.B.
      • Chalamalasetty S.B.
      • Vishnubhatla S.
      • Madan K.
      • Gamanagatti S.R.
      • Batra Y.
      • et al.
      Clinical profile, etiology and therapeutic outcome in 324 hepatocellular carcinoma patients at a tertiary care center in India.
      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.
      • Kuzuya T.
      • Katano Y.
      • Kumada T.
      • Toyoda H.
      • Nakano I.
      • Hirooka Y.
      • et al.
      Efficacy of antiviral therapy with lamivudine after initial treatment for hepatitis B virus-related hepatocellular carcinoma.
      ,
      • Li N.
      • Lai E.C.H.
      • Shi J.
      • Guo W.-X.
      • Xue J.
      • Huang B.
      • et al.
      A comparative study of antiviral therapy after resection of hepatocellular carcinoma in the immune-active phase of hepatitis B virus infection.
      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”.

      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.

      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.
      • Bajaj J.S.
      • O’Leary J.G.
      • Tandon P.
      • Wong F.
      • Garcia-Tsao G.
      • Kamath P.S.
      • et al.
      Hepatic encephalopathy is associated with mortality in patients with cirrhosis independent of other extrahepatic organ failures.
      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.
      • Reig M.
      • Forner A.
      • Rimola J.
      • Ferrer-Fábrega J.
      • Burrel M.
      • Garcia-Criado A.
      • et al.
      BCLC strategy for prognosis prediction and treatment recommendation: The 2022 update.

      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

      The following are the supplementary data to this article:

      References

        • Reig M.
        • Forner A.
        • Rimola J.
        • Ferrer-Fábrega J.
        • Burrel M.
        • Garcia-Criado A.
        • et al.
        BCLC strategy for prognosis prediction and treatment recommendation: The 2022 update.
        J Hepatol. 2022; 76: 681-693
        • Johnson P.J.
        • Berhane S.
        • Kagebayashi C.
        • Satomura S.
        • Teng M.
        • Reeves H.L.
        • et al.
        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
        • Paul S.B.
        • Chalamalasetty S.B.
        • Vishnubhatla S.
        • Madan K.
        • Gamanagatti S.R.
        • Batra Y.
        • et al.
        Clinical profile, etiology and therapeutic outcome in 324 hepatocellular carcinoma patients at a tertiary care center in India.
        Oncology. 2009; 77: 162-171
        • Kuzuya T.
        • Katano Y.
        • Kumada T.
        • Toyoda H.
        • Nakano I.
        • Hirooka Y.
        • et al.
        Efficacy of antiviral therapy with lamivudine after initial treatment for hepatitis B virus-related hepatocellular carcinoma.
        J Gastroenterol Hepatol. 2007 Nov; 22: 1929-1935
        • Li N.
        • Lai E.C.H.
        • Shi J.
        • Guo W.-X.
        • Xue J.
        • Huang B.
        • et al.
        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
      1. 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.

        • Bajaj J.S.
        • O’Leary J.G.
        • Tandon P.
        • Wong F.
        • Garcia-Tsao G.
        • Kamath P.S.
        • et al.
        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