title: Ascites and alpha-fetoprotein improve prognostic performance of Barcelona Clinic Liver Cancer staging.
abstract: OBJECTIVE
  To assess how ascites and alpha-fetoprotein (AFP) added to the Barcelona Clinic Liver Cancer (BCLC) staging predict hepatocellular carcinoma survival.
  
  
  METHODS
  The presence of underlying cirrhosis, ascites and encephalopathy, Child-Turcotte-Pugh (CTP) score, the number of nodules, and the maximum diameter of the largest nodule were determined at diagnosis for 1060 patients with hepatocellular carcinoma at a tertiary referral center for liver disease in Egypt. Demographic information, etiology of liver disease, and biochemical data (including serum bilirubin, albumin, international normalized ratio, alanine and aspartate aminotransferases, and AFP) were evaluated. Staging of the tumor was determined at the time of diagnosis using the BCLC staging system; 496 patients were stage A and 564 patients were stage B. Patients with mild ascites on initial ultrasound, computed tomography, or clinical examination, and who had a CTP score ≤ 9 were included in this analysis. All patients received therapy according to the recommended treatment based on the BCLC stage, and were monitored from the time of diagnosis to the date of death or date of data collection. The effect of the presence of ascites and AFP level on survival was analyzed.
  
  
  RESULTS
  At the time the data were censored, 123/496 (24.8%) and 218/564 (38.6%) patients with BCLC stages A and B, respectively, had died. Overall mean survival of the BCLC A and B patients during a three-year follow-up period was 31 mo [95% confidence interval (95%CI): 29.7-32.3] and 22.7 mo (95%CI: 20.7-24.8), respectively. The presence of ascites, multiple focal lesions, large tumor size, AFP level and CTP score were independent predictors of survival for the included patients on multivariate analysis (P < 0.001). Among stage A patients, 18% had ascites, 33% had AFP ≥ 200 ng/mL, and 8% had both. Their median survival in the presence of ascites was shorter if AFP was ≥ 200 ng/mL (19 mo vs 24 mo), and in the absence of ascites, patients with AFP ≥ 200 ng/mL had a shorter survival (28 mo vs 39 mo). For stage B patients, survival for the corresponding groups was 12, 18, 19 and 22 mo. The one-, two-, and three-year survival rates for stage A patients without ascites and AFP < 200 ng/mL were 94%, 77%, and 71%, respectively, and for patients with ascites and AFP ≥ 200 ng/mL were 83%, 24%, and 22%, respectively (P < 0.001). Adding ascites and AFP ≥ 200 ng/mL improved the discriminatory ability for predicting prognosis (area under the curve, 0.618 vs 0.579 for BCLC, P < 0.001).
  
  
  CONCLUSIONS
  Adding AFP and ascites to the BCLC staging classification can improve prognosis prediction for early and intermediate stages of hepatocellular carcinoma.
authors.affiliation: Asmaa I Gomaa, Wael Abdel-Razek, Mohammed Saad Hashim, Imam Waked, Hepatology Department, National Liver Institute, Menoufiya University, Shebeen El-Kom 35111, Egypt.
authors.forename: Asmaa I
authors.initials: AI
authors.lastname: Gomaa
authors.affiliation: Asmaa I Gomaa, Wael Abdel-Razek, Mohammed Saad Hashim, Imam Waked, Hepatology Department, National Liver Institute, Menoufiya University, Shebeen El-Kom 35111, Egypt.
authors.forename: Alzhraa
authors.initials: A
authors.lastname: Al-Khatib
authors.affiliation: Asmaa I Gomaa, Wael Abdel-Razek, Mohammed Saad Hashim, Imam Waked, Hepatology Department, National Liver Institute, Menoufiya University, Shebeen El-Kom 35111, Egypt.
authors.forename: Wael
authors.initials: W
authors.lastname: Abdel-Razek
authors.affiliation: Asmaa I Gomaa, Wael Abdel-Razek, Mohammed Saad Hashim, Imam Waked, Hepatology Department, National Liver Institute, Menoufiya University, Shebeen El-Kom 35111, Egypt.
authors.forename: Mohammed Saad
authors.initials: MS
authors.lastname: Hashim
authors.affiliation: Asmaa I Gomaa, Wael Abdel-Razek, Mohammed Saad Hashim, Imam Waked, Hepatology Department, National Liver Institute, Menoufiya University, Shebeen El-Kom 35111, Egypt.
authors.forename: Imam
authors.initials: I
authors.lastname: Waked
mesh_terms: D000328:Adult; D019540:Area Under Curve; D001201:Ascites / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy; D006528:Carcinoma, Hepatocellular / Q000097:blood / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy; D016009:Chi-Square Distribution; D003661:Decision Support Techniques; D004534:Egypt; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008113:Liver Neoplasms / Q000097:blood / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy; D008297:Male; D008875:Middle Aged; D008954:Models, Biological; D015999:Multivariate Analysis; D009367:Neoplasm Staging; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012372:ROC Curve; D012307:Risk Factors; D062606:Tertiary Care Centers; D013997:Time Factors; D016896:Treatment Outcome; D000509:alpha-Fetoproteins / Q000032:analysis*
chemical_list: C097353:AFP protein, human; D000509:alpha-Fetoproteins
keywords: Alpha-fetoprotein; Ascites; Barcelona Clinic Liver Cancer; Hepatocellular carcinoma; Survival