Introduction

Patients with hepatocellular carcinoma (HCC) frequently have comorbidities that limit access to treatments and might increase mortality. The Charlson comorbidity index (CCI) assigns a numeric score to 17 diseases according to their effect on mortality. In patients with cirrhosis and HCC, these variables might be excluded from the CCI (modified CCI, mCCI).

Aims & Methods

Aim of the study was to evaluate the performance of CCI and mCCI for HCC patients’ characterization.
We used data from our retrospective monocentric study of patients with first HCC diagnosis. We evaluated the performance of CCI and mCCI in dissecting our population and predicting overall survival (OS). As secondary end-point, the impact of mCCI on adherence to Barcelona Clinic Liver Cancer (BCLC) staging and treatment allocation was evaluated.

Results

The study included 385 patients (289 males, 68 years median age, 78% Child Pugh (CPT) A, 66% viral etiology) with HCC (271 BCLC 0/A, 64 B, 40 C and 10 D). According to CCI, 94% of our patients were “high-risk” (CCI≥5), 5.7% “intermediate-risk” (CCI 3-4) and 0.3% “low-risk” (CCI 0-2). These cutoffs were applied to mCCI: 21% “high-risk”, 48% “intermediate-risk”, and 31% “low-risk”. Patients' mCCI correlated with CCI (Kendall's τ=0.47; p-value< 0.0001). Overall, patients belonging to a “high” or “intermediate-risk” mCCI classes had a shorter OS as compared to “low-risk” patients (median OS 37 vs 49 vs 67 months, p-value=0.007). This was confirmed in BCLC 0/A (p-value=0.002). Moreover, “high-risk” mCCI class, worse CPT class, presence of varices, BCLC stage and AFP>200 ng/mL were independently associated to mortality [HR1.36 (95%CI 1.09-1.70, p-value=0.006; HR1.62 (95%CI 1.14-2.30), p-value=0.007; HR1.58 (95%CI 1.11-2.24), p-value=0.01; HR1.96 (95%CI 1.66-2.31) p-value<0.001; HR1.80 (1.17-2.79) p-value=0.008]. mCCI was also an independent predictor of mortality in BCLC 0/A, with higher tumor burden and worse CPT. No differences were observed in adherence to BCLC2022 algorithm and access to treatment among the mCCI risk classes.

Conclusion

mCCI better stratified patients with HCC as compared to CCI and independently predicted mortality. Implementation of a multiparametric therapeutic approach to treatment allocation including evaluation of comorbidities and frailty is warranted

Introduction

​In 2022 the BCLC staging and treatment algorithm for hepatocellular carcinoma (HCC) management has been updated (BCLC_2022), granting for higher flexibility and customized management for HCC patients as compared to the 2018 version.

Aims & Methods

Aim of the study was to evaluate the feasibility of BCLC_2022 in daily clinical practice (BCLC_2018 as benchmark), its impact on response to treatment and on overall survival (OS).
We retrospectively evaluated data of 798 prospectively followed (year 2006 to 2022) patients with de novo HCC: 187 0, 371 A, 132 B, 87 C and 21 D, according to BCLC. First line treatment allocations were discussed by a multidisciplinary team (MTD), following updated recommendations. All patients were followed until death or end of follow-up (12/2022).

Results

Overall, the feasibility if BCLC increased from 51% for the BCLC_2018 to 69% for the BCLC_2022 (p<0.001): 56% to 73% stage 0 (p=0.001), 45% to 72% stage A (p<0.001), 51% to 65% stage B (p=0.02), while no changes were registered for stage C and D. Among BCLC 0 /A patients, 130 (23%) were treated with TACE, which is a “lower priority option” for these stages according to BCLC_2022. The rate of "downward stage migration" was significantly lower with BCLC_2022 (33% to 16%, p<0.001). “Downward stage migration” without curative intent was associated with a lower proportion of complete response to first line treatment in the early stages (0% vs 77%, p=0.003 in BCLC0; 0% vs 57%, p=0.001 in BCLC A) and to a shorter OS [6 months (IQR 2-16) vs 82 months (IQR 42-132), p<0.001 in BCLC 0] as compared to BCLC_2022. Similarly in early stages patients treated with a “lower priority option” had a lower proportion of complete response (82% vs 60%, p=0.01 in BCLC 0 and 74% vs 20%, p<0.001 in BCLC A) and a shorter OS [33 (IQR 23-61) vs 74 months (IQR 42-137) p<0.001 in BCLC A] as compared to those undergoing first choice treatments. In BCLC B and C, an upward stage migration was associated to a higher achievement of complete response (17% vs 52%, p<0.001 in BCLC B and 2% vs 41% p<0.001 in BCLC C), and granted a longer OS [(63 months (IQR 36-72) vs 28 (IQR 18-44), p=0.003 in BCLC B and 21 months (IQR 15-44) vs 11 months (IQR 4-25) in BCLC C] as compared to BCLC 2022. In BCLC 0 and undergoing a “downward stage migration” without curative intent was an independent predictor of mortality [HR 6.94 (95% CI 2.27-21.20) p=0.001], alongside with age [HR 1.08 (95% CI 1.06-1.13), p<0.001] and ALBI grade 3 [HR 9.34 (95% CI 1.21-72.19), p=0.03. Conversely, “upward stage migration” was independently associated to a lower mortarlity risk both in BCLC B” [HR 0.46 (95% CI 0.27-0.80), p=0.006] and C [HR 0.50 (95% CI 0.27-0.92) p=0.03].

Conclusion

The BCLC_2022 updated version of HCC staging and treatment system allowed a greater adherence to the algorithm in clinical practice, without adversely affecting the survival of patients. Choosing a “curative option” for early HCC granted longer survival, as well as the access to treatments with curative intent permits a survival benefit in selected patients in more advanced stages.

Introduction

Treatment strategy of hepatocellular carcinoma (HCC) is a complex decision-making process that considers several variables in clinical practice. A “multiparametric therapeutic approach” has been proposed (Lancet Oncol 2023): the feasibility of all treatments is evaluated systematically in a hierarchical order, to match each patient with the optimal therapy.

Aims & Methods

The aim of the study is to validate the reliability of the new multiparametric decisional framework (MPDF) and the impact of the different variables included in the framework on the final treatment decision in clinical practice. This is a prospective ongoing study with a first monocentric phase (A) and a second multicentric validation phase. Primary endpoints are: 1) adherence to MPDF for treatment allocation, 2) identification of the relative weight of variables involved in this MPDF for treatment decision, while secondary endpoints are overall survival and radiological response after treatment. The study includes all consecutive patients with HCC managed in each center from September 1^st, 2023. The disease is staged according to Barcelona Clinic Liver Cancer (BCLC) classification, while patient’s characterization is conducted by Charlson Comorbidity Index (CCI), Liver Frailty Index (LFI), Child-Pugh (CPT) and ALBI, MELD and skeletal muscle mass index by CT. Each patient is allocated to treatment according to MPDF, BCLC 2022 was the benchmark.

Results

As of November 1st, 2023, 48 patients were recruited into phase A of the study [median age 70 (52-87) years, 81% male, 37% HCV, 27% first treatment for HCC]. Thirteen (27%) patients were classified BCLC 0, 17 (35%) A, 6 (12.5%) B, 6 (12.5%) C and 6 (12.5%) D. The median CCI was 8 (4-13), the median LFI was 4.15 (2.99-4.81). Thirty-nine (81%) patients were in CPT class A, 7 (15%) in B and 2 (4%) in C, while 32 (67%) were classified ALBI grade 1 and 16 (33%) ALBI grade 2, and the median MELD score was 8.5 (6-22). Forty-four (92%) patients received treatment through a multidisciplinary team (MDT). According to the MPDF, 9 (19%) patients were allocated to liver transplant, 5 (10%) to laparoscopic surgical resection, 10 (21%) to microwave thermal ablation (MWTA), 7 (15%) to transarterial treatments (4 TACE and 3 TARE), 3 (6%) to other locoregional therapies (2 MWTA+TACE and 1 electrochemotherapy), 6 (13%) to systemic treatment and 5 (10%) to palliative care only. In 4 cases, the MDT decided for reassessment at 3 months. The treatment allocation was coherent to the BCLC 2022 in 69% BCLC 0, 82% BCLC A, 83% BCLC B, 67% BCLC C and 100% BCLC D.

Conclusion

Preliminary data of our ongoing prospective study suggest that personalized approach for HCC treatment by MPDF is feasible in clinical practice and might help ensuring a customized approach in a standardized framework. Updated data will be presented at the meeting.

Introduction

Sarcopenia is increasingly recognized as a major prognostic factor in patients with hepatocellular carcinoma (HCC). Its evaluation may improve patient risk stratification and therapeutic decision-making

Aims & Methods

To assess the prevalence of sarcopenia among patients with hepatocellular carcinoma (HCC), identify associated factors, and evaluate the MELD-sarcopenia score as a potential predictor of mortality.
We conducted a retrospective monocentric study over a 10-year period, including patients aged over 18 years with a confirmed diagnosis of HCC based on radiological, biological, and/or histological criteria. Only patients with an available abdominal CT scan including the L3 vertebral level were included. Exclusion criteria were liver transplantation, other primary liver tumors, non-HCC malignancies, incomplete records, or poor-quality imaging. Sarcopenia was diagnosed by calculating the Total Psoas Area Index (TPAI) on CT, using thresholds of 5.45 cm²/m² for men and 3.85 cm²/m² for women. MELD and MELD-sarcopenia scores were calculated. Survival time from HCC diagnosis was recorded.

Results

Among 30 screened patients, 5 were excluded due to missing imaging. In the final cohort of 25 patients, the prevalence of sarcopenia was 52%. Compared to non-sarcopenic patients, sarcopenic patients were older (67.6 vs 56 years) and more often male. The most frequent etiology in sarcopenic patients was hepatitis C (46.2%), while hepatitis B was predominant in non-sarcopenic patients (58.3%). Cirrhosis was mostly compensated in both groups. HCC was typically unifocal, infiltrative, and multilobar in both groups. The mean time from HCC diagnosis to death was shorter in sarcopenic patients (13.4 vs 33.9 months). Male sex and older age were significantly associated with sarcopenia (p < 0.05), whereas tumor characteristics, Child-Pugh class, and biological tests were not. Kaplan-Meier analysis showed a tendency toward worse survival in patients with higher MELD-sarcopenia scores, although the difference was not statistically significant (p > 0.05).

Table : Comparison of clinical and survival characteristics between sarcopenic and non-sarcopenic patients with hepatocellular carcinoma

Conclusion

Sarcopenia is highly prevalent among patients with HCC and is independently associated with male sex and older age. The MELD-sarcopenia score appears to be a promising tool for mortality risk stratification and may aid clinical decision-making.

References

https://pubmed.ncbi.nlm.nih.gov/21893129/

Disclosure

There were no conflicts of interest.