Prognostic indicators in hepatocellular carcinoma: a systematic review of 72 studies

BACKGROUND: Although there are many studies of the predictors of death in hepatocellular carcinoma (HCC), most combine patients with and without cirrhosis and many combine those with compensated and decompensated cirrhosis. OBJECTIVE: To perform a systematic review of the literature evaluating the predictors of death in patients with cirrhosis and HCC and to evaluate whether the predictors differ between patients with compensated and decompensated cirrhosis. METHODS: Inclusion criteria: (i) publication in English, (ii) adult patients, (c) >80% of the patients had cirrhosis, (iv) follow-up >6 months and (v) multivariable analysis. Quality was based on the accepted quality criteria for prognostic studies. RESULTS: Of the 1106 references obtained, 947 were excluded because they did not meet the inclusion criteria. A total of 23 968 patients were included in 72 studies (median, 177/study); 77% male, median age 64, 55% Child–Pugh class A. The most robust predictors of death were portal vein thrombosis, tumour size, α-foetoprotein and Child–Pugh class. Sensitivity analysis using only 15 ‘good’ studies and 22 studies in which all patients had cirrhosis yielded the same variables. In the studies including mostly compensated or decompensated patients, the predictors were both liver and tumour related. However, these studies were few and the results were not robust. CONCLUSIONS: This systematic review of 72 studies shows that the most robust predictors of death in patients with cirrhosis and HCC are tumour related and liver related. Future prognostic studies should include these predictors and should be performed in specific patient populations to determine whether specific prognostic indicators are more relevant at different stages of cirrhosis.