title: Barcelona Clinic Liver Cancer staging and transplant survival benefit for patients with hepatocellular carcinoma: a multicentre, cohort study.
abstract: BACKGROUND
  Allocation of deceased-donor livers to patients with chronic liver failure is improved by prioritising patients by 5-year liver transplantation survival benefit. The Barcelona Clinic Liver Cancer (BCLC) staging has been proposed as the standard means to assess for prognosis of patients with hepatocellular carcinoma. We aimed to create a prediction model linking the BCLC stage of patients with hepatocellular carcinoma to their 5-year liver transplant benefit.
  
  
  METHODS
  A large cohort of consecutive patients with hepatocellular carcinoma (n=1328) from the ITA.LI.CA database (n=2951) were judged as potentially eligible for liver transplantation according to the following criteria: absence of macroscopic vascular invasion or metastases, age 70 years or younger, and absence of relevant extra-hepatic comorbidities. To assess the correlation between BCLC staging and non-liver transplantation survival, we did Cox univariate and multivariate analyses including the following covariates: BCLC stage, year of diagnosis, age, sex, cause of cirrhosis, model for end-stage liver disease score, α-fetoprotein concentrations, and treatment. Liver-transplantation survival benefit for patients was calculated, using Monte Carlo simulation analysis, as the patient's 5-year life expectancy with liver transplantation (estimated by the Metroticket model) minus the 5-year life expectancy without liver transplantation according to BCLC stage.
  
  
  RESULTS
  83 (6%) of 1328 patients had BCLC 0 stage disease, 614 (46%) had BCLC A, 500 (38%) had BCLC B-C, and 131 (10%) had BCLC D. In the Cox non-liver transplantation survival multivariate model, hazard ratios associated with increasing BCLC stages were 1.530 (95% CI 1.107-2.116) for BCLC A versus BCLC 0, 1.572 (1.350-1.830) for BCLC B-C versus BCLC A, and 1.470 (1.164-1.856) for BCLC D versus BCLC B-C. Results of the Monte Carlo simulation analysis confirmed the significant effect of BCLC classification on transplant benefit; in the adjusted model, a median 5-year transplant benefit of 11.19 months (IQR 10.73-11.67) for BCLC 0, 13.49 months (11.51-15.57) for BCLC A, 17.36 months (15.06-19.28) for BCLC B-C, and 28.46 months (26.38-30.34) for BCLC D.
  
  
  CONCLUSIONS
  Liver transplantation could result in survival benefit for patients with hepatocellular carcinoma and advanced liver cirrhosis (BCLC stage D) and in those with intermediate tumours (BCLC stages B-C), regardless of the nodule number-size criteria (ie, Milan criteria), provided that macroscopic vascular invasion and extra-hepatic disease are absent.
  
  
  BACKGROUND
  None.
authors.affiliation: Unità di Chirurgia Epatobiliare e Trapianto Epatico, Azienda Ospedaliera, Università di Padova, Padova, Italy. alessandro.vitale@unipd.it
authors.forename: Alessandro
authors.initials: A
authors.lastname: Vitale
authors.forename: Rafael Ramirez
authors.initials: RR
authors.lastname: Morales
authors.forename: Giacomo
authors.initials: G
authors.lastname: Zanus
authors.forename: Fabio
authors.initials: F
authors.lastname: Farinati
authors.forename: Patrizia
authors.initials: P
authors.lastname: Burra
authors.forename: Paolo
authors.initials: P
authors.lastname: Angeli
authors.forename: Anna Chiara
authors.initials: AC
authors.lastname: Frigo
authors.forename: Paolo
authors.initials: P
authors.lastname: Del Poggio
authors.forename: Gianludovico
authors.initials: G
authors.lastname: Rapaccini
authors.forename: Maria Anna
authors.initials: MA
authors.lastname: Di Nolfo
authors.forename: Luisa
authors.initials: L
authors.lastname: Benvegnù
authors.forename: Marco
authors.initials: M
authors.lastname: Zoli
authors.forename: Franco
authors.initials: F
authors.lastname: Borzio
authors.forename: Edoardo Giovanni
authors.initials: EG
authors.lastname: Giannini
authors.forename: Eugenio
authors.initials: E
authors.lastname: Caturelli
authors.forename: Maria
authors.initials: M
authors.lastname: Chiaramonte
authors.forename: Franco
authors.initials: F
authors.lastname: Trevisani
authors.forename: Umberto
authors.initials: U
authors.lastname: Cillo
mesh_terms: D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000628:therapy*; D015331:Cohort Studies; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D008113:Liver Neoplasms / Q000628:therapy*; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D009010:Monte Carlo Method; D009367:Neoplasm Staging; D012189:Retrospective Studies; D016896:Treatment Outcome