title: Simplified staging for hepatocellular carcinoma.
abstract: OBJECTIVE
  The current American Joint Committee on Cancer (AJCC) staging system for hepatocellular carcinoma (HCC) fails to stratify patients adequately with respect to prognosis.
  
  
  METHODS
  The ability of the currently proposed tumor (T) categories to effectively stratify the survival of 557 patients who underwent complete resection for HCC at four centers was examined. Independent predictors of survival were combined into a new staging system.
  
  
  RESULTS
  Using the current AJCC T classification, patients with T1 and T2 tumors had similar 5-year survivals (P =.6). In addition, the survival of patients with multiple bilobar tumors (T4) matched that of T3 patients (P =.5). Independent predictors of death were major vascular invasion (P <.001), microvascular invasion (P =.001), severe fibrosis/cirrhosis of the host liver (P =.001), multiple tumors (P =.007), and tumor size greater than 5 cm (P =.01). Based on our results, a simplified stratification is proposed: (a) patients with a single tumor and no microvascular invasion, (b) patients with a single tumor and microvascular invasion or multiple tumors, none more than 5 cm, and (c) patients with either multiple tumors, any more than 5 cm, or tumor with major vascular invasion (P <.001). Severe fibrosis/cirrhosis had a negative impact on survival within all categories. The survival of patients with lymph node involvement matched that of patients with major vascular invasion (P =.3).
  
  
  CONCLUSIONS
  The current AJCC staging system for HCC is unnecessarily complex. We propose a simplified model of stratification that is based on vascular invasion, tumor number, and tumor size and incorporates the effect of fibrosis on survival.
authors.affiliation: International Cooperative Study Group on Hepatocellular Carcinoma, Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, 77030, USA. jvauthey@mdanderson.org
authors.forename: Jean-Nicolas
authors.initials: JN
authors.lastname: Vauthey
authors.forename: Gregory Y
authors.initials: GY
authors.lastname: Lauwers
authors.forename: Nestor F
authors.initials: NF
authors.lastname: Esnaola
authors.forename: Kim-Anh
authors.initials: KA
authors.lastname: Do
authors.forename: Jacques
authors.initials: J
authors.lastname: Belghiti
authors.forename: Nadeem
authors.initials: N
authors.lastname: Mirza
authors.forename: Steven A
authors.initials: SA
authors.lastname: Curley
authors.forename: Lee M
authors.initials: LM
authors.lastname: Ellis
authors.forename: Jean-Marc
authors.initials: JM
authors.lastname: Regimbeau
authors.forename: Asif
authors.initials: A
authors.lastname: Rashid
authors.forename: Karen R
authors.initials: KR
authors.lastname: Cleary
authors.forename: David M
authors.initials: DM
authors.lastname: Nagorney
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D006528:Carcinoma, Hepatocellular / Q000401:mortality / Q000473:pathology*; D005260:Female; D006801:Humans; D008113:Liver Neoplasms / Q000401:mortality / Q000473:pathology*; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging / Q000379:methods*; D011379:Prognosis; D016016:Proportional Hazards Models; D015996:Survival Rate; D014481:United States