title: A new Child-Turcotte-Pugh class 0 for patients with hepatocellular carcinoma: determinants, prognostic impact and ability to improve the current staging systems.
abstract: OBJECTIVE
  Majority of patients with hepatocellular carcinoma (HCC) belonged to Child-Turcotte-Pugh (CTP) class A. We aimed to identify a new class of patients with very well-preserved liver function and analyze its impact on outcome prediction, tumor staging and treatment allocation.
  
  
  METHODS
  A total of 2654 HCC patients were retrospectively analyzed. The prognostic ability was compared by the Akaike information criterion (AIC).
  
  
  RESULTS
  The CTP class 0 was defined by fulfilling all criteria of albumin ≧4 g/dL, bilirubin ≦0.8 mg/dL, prothrombin time prolongation <0 seconds, no ascites and encephalopathy. A total of 23% of patients of CTP class A were reclassified as CTP class 0. Patients with CTP class 0 had a higher serum sodium level, lower serum creatinine, alanine aminotransferase, α-fetoprotein levels, shorter prothrombin time, better general well-being, smaller tumor burden with more solitary nodules, lower rates of vascular invasion, ascites formation, hepatic encephalopathy, more frequently treated with curative interventions and better Barcelona Clinic Liver Cancer (BCLC) stages (all p<0.001). In the Cox proportional hazards model, the adjusted hazard ratios for CTP class A, B and C were 1.739, 3.120 and 5.107, respectively, compared to class 0 (all p<0.001). Reassigning patients with CTP class 0, A, B, B and C to stage 0, A, B, C and D, respectively, provided the lowest AIC score among all BCLC-based models.
  
  
  CONCLUSIONS
  The proposal of CTP class 0 independently predicted better survival in HCC patients. Modification of tumor staging systems according to the modified CTP classification further enhances their prognostic ability.
authors.affiliation: Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Department of Medicine, Yuanshan Branch of Taipei Veterans General Hospital, Taipei, Taiwan.
authors.forename: Yun-Hsuan
authors.initials: YH
authors.lastname: Lee
authors.affiliation: Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Biostatistics, University of California Los Angeles, Los Angeles, California, United States of America.
authors.forename: Chia-Yang
authors.initials: CY
authors.lastname: Hsu
authors.affiliation: Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Department of Medicine, Yuanshan Branch of Taipei Veterans General Hospital, Taipei, Taiwan.
authors.forename: Chen-Wei
authors.initials: CW
authors.lastname: Chu
authors.affiliation: Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
authors.forename: Po-Hong
authors.initials: PH
authors.lastname: Liu
authors.affiliation: Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.
authors.forename: Cheng-Yuan
authors.initials: CY
authors.lastname: Hsia
authors.affiliation: Institute of Clinical Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
authors.forename: Yi-Hsiang
authors.initials: YH
authors.lastname: Huang
authors.affiliation: Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
authors.forename: Chien-Wei
authors.initials: CW
authors.lastname: Su
authors.affiliation: Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.
authors.forename: Yi-You
authors.initials: YY
authors.lastname: Chiou
authors.affiliation: Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
authors.forename: Han-Chieh
authors.initials: HC
authors.lastname: Lin
authors.affiliation: Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Institute of Pharmacology, National Yang-Ming University School of Medicine, Taipei, Taiwan; Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
authors.forename: Teh-Ia
authors.initials: TI
authors.lastname: Huo
mesh_terms: D006528:Carcinoma, Hepatocellular / Q000175:diagnosis / Q000401:mortality / Q000473:pathology / Q000628:therapy; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D008113:Liver Neoplasms / Q000097:blood / Q000175:diagnosis / Q000401:mortality / Q000473:pathology / Q000628:therapy; D008297:Male; D009367:Neoplasm Staging; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D015996:Survival Rate