Prognostic scores for hepatocellular carcinoma: none is the winner

Prognostic scores for hepatocellular carcinoma: none is the winner Cancer classification and indication of treatment are critical steps in the management of patients with hepatocellular carci-noma (HCC). The prediction of outcome is relevant to provide adequate information to patients and relatives, both at the time of treatment selection and after the application of therapy. Tumour staging describes the extent of an individual's tumour burden in the original primary organ and spread throughout the body, and other cofactors such as age or histological grade are only seldom considered. This is common to all malignancies and diseases. However, whereas for most neoplasms prognosis and treatment are largely dictated by tumour stage at the time of diagnosis, the scenario is more complex in patients with HCC. It is well known that cirrhosis underlies HCC in most of the patients and the functional impairment of the underlying liver has a significant impact on prognosis, irrespective of the tumour stage. Moreover, liver function defines the capacity to indicate treatments with potential deleterious effects on the liver (1). This is well established in early tumours, in which resection may be contraindicated because of the deterioration of liver functional status and the same applies to patients with multifocal HCC that could be considered for locoregional therapies such as chemoembolization, in whom liver decom-pensation unequivocally argues against its indication. Several staging systems have been developed for the classification of patients with HCC. The best known and assessed include eight systems based on clinical items: Okuda (2), Cancer of Liver Italian Program (CLIP) (3), Barcelona Clinic Liver Cancer (BCLC) (4), GRoupe d'Etude et de Traitement du Carcinoma Hépatocellulaire (GRETCH) (5), Tumour node metastasis (TNM) (6), Chinese University Prognostic Index (CUPI) (7), Japanese Integrated System (JIS) (8) and one molecular staging system, the estrogen receptor (ER) (9) classification proposed by Villa et al. A major problem of the studies on prediction of patient outcomes from HCC on cirrhosis arises from a lack of prognostic tools able to adequately express the medical complexity of the syndrome. These tools could support an objective risk stratification in interventional studies, quality of care evaluation and allocation of health care resources. Unfortunately , no accurate mortality risk estimate is yet available to the hepatologist as decision-making support in order to avoid unethical and futile care of HCC patients. For instance, if the difference in overall survival with or without a new molecular-targeted therapy can be …