Advanced hepatocellular carcinoma: which staging systems best predict prognosis?

PURPOSE: The purpose of cancer staging systems is to accurately predict patient prognosis. The outcome of advanced hepatocellular carcinoma (HCC) depends on both the cancer stage and the extent of liver dysfunction. Many staging systems that include both aspects have been developed. It remains unknown, however, which of these systems is optimal for predicting patient survival. PATIENTS AND METHODS: Patients with advanced HCC treated over a 5-year period at Memorial Sloan-Kettering Cancer Center were identified from an electronic medical record database. Patients with sufficient data for utilization in all staging systems were included. TNM sixth edition, Okuda, Barcelona Clinic Liver Cancer (BCLC), Cancer of the Liver Italian Program (CLIP), Chinese University Prognostic Index (CUPI), Japan Integrated Staging (JIS), and Groupe d'Etude et de Traitement du Carcinome Hepatocellulaire (GETCH) systems were ranked on the basis of their accuracy at predicting survival by using concordance index (c-index). Other independent prognostic variables were also identified. RESULTS: Overall, 187 eligible patients were identified and were staged by using the seven staging systems. CLIP, CUPI, and GETCH were the three top-ranking staging systems. BCLC and TNM sixth edition lacked any meaningful prognostic discrimination. Performance status, AST, abdominal pain, and esophageal varices improved the discriminatory ability of CLIP. CONCLUSION: In our selected patient population, CLIP, CUPI, and GETCH were the most informative staging systems in predicting survival in patients with advanced HCC. Prospective validation is required to determine if they can be accurately used to stratify patients in clinical trials and to direct the appropriate need for systemic therapy versus best supportive care. BCLC and TNM sixth edition were not helpful in predicting survival outcome, and their use is not supported by our data.

Primary adenocarcinoma of the anus treated with combined modality therapy.

PURPOSE: The purpose of this study was to determine the local control and survival of patients with adenocarcinoma of the anus who received combined modality therapy as a component of their treatment. METHODS: Thirteen patients with primary anal adenocarcinoma (T1: 1, T2: 4, T3: 3, T4: 5; and N0: 9, N1: 2, N2: 2) were treated between 1989 and 2001 in the Department of Radiation Oncology at Memorial Sloan Kettering Cancer Center. Three general treatment approaches were used that were based on physician and patient preference as well as tumor stage. These included preoperative combined modality therapy followed by abdominoperineal resection (n = 5), with four of the five receiving postoperative chemotherapy; local excision followed by postoperative radiation alone or combined modality therapy (n = 5); and abdominoperineal resection followed by postoperative combined modality therapy (n = 3). Two patients received brachytherapy. RESULTS: With a median follow-up of 19 months, the median survival was 26 months, the local failure rate was 37 percent, and the two-year actuarial survival was 62 percent. In the subset of eight patients treated with abdominoperineal resection and preoperative or postoperative radiation or combined modality therapy, local control was 63 percent, and three of eight are without evidence of disease. Of the five patients who underwent a local excision followed by postoperative radiation or combined modality therapy, the local control rate was 60 percent, with one of the local failures salvaged by abdominoperineal resection and one of five patients without evidence of disease. CONCLUSION: Although the experience is limited, our data suggest that the combination of abdominoperineal resection and combined modality therapy is a reasonable approach for this rare tumor.