13 Aug 2014

Researchers from the Department of Surgery of Li Ka Shing Faculty of Medicine, The University of Hong Kong (HKU) and Queen Mary Hospital, have developed Asia’s first liver cancer staging system with treatment guidelines, called the Hong Kong Liver Cancer (HKLC) staging system. The home-grown breakthrough, which recently made its global debut in Gastroenterology, the premiere journal in the field of gastroenterology and hepatology, has already received widespread international recognition as probably the best staging system for liver cancer.

“Liver cancer is relatively rare in western countries but widespread in Asia, which accounts for more than 80% of all liver cancer deaths worldwide each year,” explained Professor Ronnie Poon Tung-ping, Suen Chi-Sun Professor in Surgery, Chair Professor and Chief of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Li Ka Shing Faculty of Medicine, HKU. “Improving treatment guideline is critical to reducing deaths locally and globally from the disease. By providing better prognostic classification and newer, more aggressive treatment strategies than existing staging systems, HKLC staging yields a better survival outcome and cure rate for liver cancer patients.”

In addition to broadening the surgical indications for liver cancer compared with existing systems, the new HKLC system is more responsive to the unique risk factors in Asian populations. It classifies liver cancer patients into five stages, rather than the current four, according to their performance status, liver function and tumour extent. Professor Poon is confident that HKLC staging will have a significant positive impact on disease outcome by optimising diagnosis, clinical management and treatment.

Development of Hong Kong Liver Cancer (HKLC) Staging System and Guidelines
Data from more than 3,800 patients with primary liver cancer treated at Queen Mary Hospital in Hong Kong from 1995 to 2008 were collected and statistically analysed to develop a new staging system and treatment guidelines for liver cancer, which were then compared with the Barcelona Clinic Liver Cancer (BCLC) staging system in terms of impact on the long-term survival of liver cancer patients. The HKLC staging system classifies liver cancer patients into five stages according to their performance status, liver function and tumour extent. This new staging system recommends more aggressive surgical treatment for advanced liver cancer confined to the liver, including patients with multiple tumours or tumours with vascular invasion in the liver, for whom BCLC staging considers surgery an absolute contraindication and would recommend palliative treatment only. Treatment according to the HKLC staging system doubled overall median survival of patients as compared to BCLC staging (16.6 vs. 8.9 months). Notably, even patients with multiple tumours or vascular invasion had a five-year survival rate of 50% compared with 0% if they were treated with drug therapy alone as recommended by BCLC staging, and a significant portion of these patients were cured by surgery.

Staging System and Treatment Algorithm for Liver Cancer
80% of liver cancer cases occur in patients with cirrhosis related to viral hepatitis B and C infection or alcoholism. The prognosis of patients and treatment options depend not only on the status of the tumour but also on liver function. Hence, prognostic staging for liver cancer is more complicated than for other cancers. A number of staging systems for liver cancer developed in different parts of the world take into account both tumour status and liver function, yet only the BCLC staging system developed in 1999 by a Spanish group of liver cancer clinicians has been widely adopted in many regions of the world because it was hitherto the only staging system to link prognostic classification to treatment guidelines.

Limitations of the BCLC Staging System
The BCLC staging system for liver cancer is the most popular treatment algorithm used in Western countries but not in Asia. The BCLC staging was developed based on limited experience of treatment of liver cancer in the West from a small cohort of patients, and the guidelines are considered too conservative by many Asian experts. Patients with multiple tumours or vascular invasion, for example, are excluded from surgical treatment, hence deprived of the potential to be cured. An appropriate prognostic staging system with treatment guidelines that can prolong survival and cure more liver cancer patients has been long anticipated. The Hong Kong Liver Cancer staging system is expected to replace BCLC as the new standard guideline for treatment of liver cancer worldwide with improved patient outcome.

Liver Cancer in Hong Kong and Asia
Liver cancer is the fifth ranking cancer in the world, accounting for 5.4% of all cancer cases. More than 80% of the world’s liver cancer cases occur in Asia. Mainland China alone accounts for more than 55% of the world’s close to one million new liver cancer cases every year, and liver cancer is the second most common cancer in China. Liver cancer is the third leading cause of cancer death in Hong Kong, with about 1,900 new cases per year. The commonest cause of liver cancer is hepatitis B viral (HBV) infection, followed by hepatitis C viral infection and alcoholic cirrhosis. Surgical resection is the main curative treatment for liver cancer. Although liver transplantation provides an alternative curative treatment for early liver cancer, its application is limited by the shortage of liver donors. In recent years, new modalities of treatment such as thermal ablation, transarterial therapies and molecular targeted therapy have been developed for treatment of different stages of liver cancer and have improved patient survival. However, selection of the best treatment protocol for a liver cancer patient remains a major challenge for clinicians. The launch of the HKLC staging system represents a major new direction in the field of liver disease, offering a more valid and reliable approach to liver cancer treatment and bringing new hope for victims of the devastating disease.

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