Patients with advanced hepatocellular carcinoma need a personalized management: A lesson from clinical practice

E.G. Giannini, L. Bucci, F. Garuti, M. Brunacci, B. Lenzi, M. Valente, E. Caturelli, G. Cabibbo, F. Piscaglia, R. Virdone, M. Felder, F. Ciccarese, F.G. Foschi, R. Sacco, G. Svegliati Baroni, F. Farinati, G.L. Rapaccini, A. Olivani, A. Gasbarrini, M. Di MarcoF. Morisco, M. Zoli, A. Masotto, F. Borzio, L. Benvegnù, F. Marra, A. Colecchia, G. Nardone, M. Bernardi, F. Trevisani, for the Italian Liver Cancer (ITA.LI.CA) group

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The Barcelona Clinic Liver Cancer (BCLC) advanced stage (BCLC C) of hepatocellular carcinoma (HCC) includes a heterogeneous population, where sorafenib alone is the recommended treatment. In this study, our aim was to assess treatment and overall survival (OS) of BCLC C patients subclassified according to clinical features (performance status [PS], macrovascular invasion [MVI], extrahepatic spread [EHS] or MVI + EHS) determining their allocation to this stage. From the Italian Liver Cancer database, we analyzed 835 consecutive BCLC C patients diagnosed between 2008 and 2014. Patients were subclassified as: PS1 alone (n = 385; 46.1%), PS2 alone (n = 146; 17.5%), MVI (n = 224; 26.8%), EHS (n = 51; 6.1%), and MVI + EHS (n = 29; 3.5%). MVI, EHS, and MVI + EHS patients had larger and multifocal/massive HCCs and higher alpha-fetoprotein (AFP) levels than PS1 and PS2 patients. Median OS significantly declined from PS1 (38.6 months) to PS2 (22.3 months), EHS (11.2 months), MVI (8.2 months), and MVI + EHS (3.1 months; P <0.001). Among MVI patients, OS was longer in those with peripheral than with central (portal trunk) MVI (11.2 vs. 7.1 months; P = 0.005). The most frequent treatments were: curative approaches in PS1 (39.7%), supportive therapy in PS2 (41.8%), sorafenib in MVI (39.3%) and EHS (37.3%), and best supportive care in MVI + EHS patients (51.7%). Independent prognostic factors were: Model for End-stage Liver Disease score, Child-Pugh class, ascites, platelet count, albumin, tumor size, MVI, EHS, AFP levels, and treatment type. Conclusion: BCLC C stage does not identify patients homogeneous enough to be allocated to a single stage. PS1 alone is not sufficient to include a patient into this stage. The remaining patients should be subclassified according to PS and tumor features, and new patient-tailored therapeutic indications are needed. (Hepatology 2018;67:1784-1796). © 2017 by the American Association for the Study of Liver Diseases.
Original languageEnglish
Pages (from-to)1784-1796
Number of pages13
Issue number5
Publication statusPublished - 2018


  • albumin
  • alpha fetoprotein
  • sorafenib
  • alpha fetoprotein, adult
  • advanced cancer
  • aged
  • albumin blood level
  • alpha fetoprotein blood level
  • Article
  • ascites
  • cancer chemotherapy
  • cancer diagnosis
  • cancer patient
  • cancer prognosis
  • cancer survival
  • cause of death
  • chemoembolization
  • Child Pugh score
  • clinical feature
  • clinical practice
  • computer assisted tomography
  • female
  • histology
  • human
  • liver cell carcinoma
  • liver graft
  • liver metastasis
  • liver resection
  • major clinical study
  • male
  • Model For End Stage Liver Disease Score
  • nuclear magnetic resonance imaging
  • overall survival
  • personalized medicine
  • platelet count
  • priority journal
  • radioembolization
  • tumor invasion
  • tumor volume
  • cancer staging
  • factual database
  • liver
  • liver tumor
  • metabolism
  • middle aged
  • mortality
  • pathology
  • procedures
  • prognosis
  • retrospective study
  • survival analysis
  • treatment outcome
  • very elderly, Aged
  • Aged, 80 and over
  • alpha-Fetoproteins
  • Carcinoma, Hepatocellular
  • Databases, Factual
  • Female
  • Humans
  • Liver
  • Liver Neoplasms
  • Male
  • Middle Aged
  • Neoplasm Staging
  • Precision Medicine
  • Prognosis
  • Retrospective Studies
  • Survival Analysis
  • Treatment Outcome


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