Kudo Masatoshi, Chung Hobyung, Osaki Yukio
Department of Gastroenterology and Hepatology, Kinki University School of Medicine, 377-2 Ohno-Higashi, Osaka-Sayama 589-8511, Japan.
J Gastroenterol. 2003;38(3):207-15. doi: 10.1007/s005350300038.
A clinical staging system for cancer patients provides guidance for patient assessment and making therapeutic decisions. It is useful in deciding whether to treat a patient aggressively, and in avoiding the overtreatment of patients who would not tolerate the treatment or patients whose life expectancy rules out any chance of treatment. Clinical staging is also an essential tool for comparison between groups in therapeutic trials and for comparison between different studies. The current classifications most commonly used for hepatocellular carcinoma (HCC) are the Okuda stages, the Child-Pugh staging system, tumor node metastasis (TNM) staging, and the Cancer of the Liver Italian Program (CLIP) score. Among these, the CLIP score is currently the most commonly used integrated staging score, including both tumor stage and liver disease stage. Although the CLIP score has been well validated by many authors in terms of its prognostic value in HCC patients, this score has some problems and limitations when applied to currently diagnosed HCC patients, who are diagnosed in the early stage of disease. First, the CLIP score can discriminate score 0- to 3-patient populations, but it is not able to discriminate score 4- to 6-patient groups. Second, the definition of tumor morphology in the best prognostic group is too advanced, i.e., uninodular and a tumor extent of less than 50% of the liver. As a result, the prognosis of the CLIP system best prognostic group is not so good. In other words, this system cannot identify the best prognostic group who would benefit from curative and aggressive treatment. Third, nearly 80% of the patient population is classified as having a CLIP score of 0-2, as confirmed by many studies, which shows poor stratification ability. In contrast, a new staging system based on the Liver Cancer Study Group of Japan (LCSGJ), the Japan Integrated Staging (JIS) score is currently proposed in Japan. This staging system combines Child-Pugh grade (grade A, score 0; grade B, score 1; grade C, score 2) and TNM staging by the LCSGJ criteria (stage I, score 0; stage II, score 1; stage III, score 2; stage IV, score 3). The stratification ability of the JIS scoring system is much better than that of the CLIP scoring system. The JIS scoring system also performed better than the CLIP scoring system in selecting the best prognostic patient group. The cumulative 10-year survival rates of the best prognostic groups in the CLIP staging system (CLIP score 0) and JIS staging system (JIS score 0) were 23% and 65%, respectively (P < 0.01). All scoring systems arise as a compromise between simplicity and discriminatory ability. We confirmed that the JIS score increases predictive efficacy, while remaining simple compared with the CLIP score. Because the JIS score is quite easily obtained and is objective, we strongly propose it for widespread use as a prognostic staging system for HCC in clinical practice.
癌症患者的临床分期系统为患者评估和制定治疗决策提供指导。它有助于决定是否对患者进行积极治疗，避免对无法耐受治疗的患者或预期寿命不允许进行任何治疗的患者进行过度治疗。临床分期也是治疗试验中不同组之间以及不同研究之间进行比较的重要工具。目前最常用于肝细胞癌（HCC）的分类是奥田分期、Child-Pugh分期系统、肿瘤-淋巴结-转移（TNM）分期以及意大利肝癌项目（CLIP）评分。其中，CLIP评分是目前最常用的综合分期评分，包括肿瘤分期和肝病分期。尽管许多作者已充分验证CLIP评分在HCC患者中的预后价值，但该评分应用于目前早期诊断的HCC患者时存在一些问题和局限性。首先，CLIP评分能够区分0至3分的患者群体，但无法区分4至6分的患者组。其次，最佳预后组中肿瘤形态的定义过于晚期，即单结节且肿瘤范围小于肝脏的50%。因此，CLIP系统最佳预后组的预后并非很好。换句话说，该系统无法识别出能从根治性和积极治疗中获益的最佳预后组。第三，许多研究证实，近80%的患者群体CLIP评分为0至2分，这表明其分层能力较差。相比之下，日本目前提出了一种基于日本肝癌研究组（LCSGJ）的新分期系统——日本综合分期（JIS）评分。该分期系统将Child-Pugh分级（A级，评分为0；B级，评分为1；C级，评分为2）与LCSGJ标准的TNM分期（I期，评分为0；II期，评分为1；III期，评分为2；IV期，评分为3）相结合。JIS评分系统的分层能力远优于CLIP评分系统。在选择最佳预后患者组方面，JIS评分系统也比CLIP评分系统表现更好。CLIP分期系统（CLIP评分为0）和JIS分期系统（JIS评分为0）中最佳预后组的累积10年生存率分别为23%和65%（P<0.01）。所有评分系统都是在简单性和区分能力之间权衡产生的。我们证实，JIS评分提高了预测效能，同时与CLIP评分相比仍保持简单。由于JIS评分很容易获得且客观，我们强烈建议在临床实践中广泛将其用作HCC的预后分期系统。
