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Improving the accuracy of outcome prediction for hepatocellular carcinoma: Asia strategies

To the Editor, We read with interest the paper ‘Treatment and the prognosis of hepatocellular carcinoma in Asia’ published in an upcoming issue of Liver International.1 It is a comprehensive review specifically focusing on the treatment and prognosis in Asian patients with hepatocellular carcinoma (HCC). A few concerns from different perspectives may deserve the readers' attention. As outlined in Torimura and Iwamoto’s study,1 Japan, Korea, Taiwan, Hong Kong and China have adopted different yet very similar approaches for HCC patients according to the Barcelona Clinic Liver Cancer (BCLC) system. Notably, investigators have proposed an alternative methodology by using a scorebased prediction model. A recent example is the MESH (model to estimate survival for HCC) system.2 The MESH score allocated 1 point for each of the following variables: large tumour, vascular invasion or metastasis, ChildTurcottePugh score ≥6, performance status ≥2, serum ɑfetoprotein (AFP) level ≥20 ng/mL and serum alkaline phosphatase ≥200 IU/L with a score range of 0– 6 points, or 7 prognostic groups. The predictive accuracy of the MESH scores remained fairly stable in patients with different viral hepatitisrelated HCC. In addition, the MESH score can discriminate survival for patients from early to advanced cancer stage. Another method is by using the concept of total tumour volume as a continuous variable to predict patient outcome. Based on this approach, we have constructed a novel prognostic model, the Taipei Integrated Scoring system,3 which shows a better prognostic ability across different patient subgroups. Moreover, for patients specifically with advanced cancer stage, we have developed an albuminbilirubin (ALBI) gradebased staging model for HCC beyond the Milan criteria.4 Six factors were identified as independent predictors of decreased survival: ALBI grade 2, ALBI grade 3, serum AFP ≥100 ng/mL, total tumour volume ≥250 cm3, ascites, performance status, and vascular invasion or metastasis, with a score range from 0 to 7 (8 groups). This model was associated with the best prognostic ability among different HCC staging systems to predict survival in patients beyond the Milan criteria. Importantly, its ability remained consistently stable in different treatment subgroups and viral etiologies. To assess the outcome of HCC, another commonly used strategy is to establish a prognostic nomogram. A nomogram is a graphic presentation of a multivariable model that generates numerical probabilities of an event. Because of its convenience in clinical application, several nomograms have been developed to predict the prognosis in various cancers.57 A unique feature of the nomogram is that it can provide evidencebased, highly accurate risk estimation of a specific event at an individual level to improve clinical decisionmaking. In this regard, our recent study indicates that a nomogram based on ALBI grade and BCLC system for outcome prediction is a simple and feasible strategy. Lastly, new prognostic biomarkers, such as EZ (easy)ALBI grade, an updated version of ALBI grade,8 should be considered to incorporate into the currently used staging models or nomograms to further enhance the predictive accuracy. Taken all together, a tighter collaboration from independent study groups in Asia is required to establish a better and more userfriendly staging system for HCC.