The management and prognosis of patients with hepatocellular carcinoma: What has changed during 20 years?

초록

Background There has been a remarkable progress in the management of hepatocellular carcinoma (HCC) after the introduction of vaccination program, antiviral treatment for chronic hepatitis B (CHB), and radiofrequency ablation (RFA) for early HCC but its impact on the prognosis has not been clarified. Therefore, this study aimed to evaluate the effect of improved management of HCC by comparing the past and present clinical characteristics and prognosis of HCC patients. Methods This study was based on two cohorts (n=1318) according to the time of HCC diagnosis: 479 patients (36.3%) in cohort 1 comprised patients who were diagnosed as HCC from year 1986-1992 while 839 patients (65.7%) in cohort 2 included HCC patients from year 2006-2012. Results The most common cause of liver disease was HBV for both cohorts (66.2% and 66.0%). However, age at the time of diagnosis was significantly older in cohort 2 compared to cohort 1 (53.1±10.4 vs 59.2±11.3, P<0.001) while Child-Pugh (7.0±2.3 vs. 6.5±1.8, P<0.001) and MELD (8.4±2.1 vs. 8.1±1.8, P=0.008) scores were significantly higher in the cohort 1 compared to cohort 2. Most of patients in the cohort 1 was diagnosed as HCC during the evaluation of symptoms related with HCC or liver disease (81.4%) while patients in the cohort 2 were diagnosed as HCC incidentally during follow-up for the underlying liver disease and during general health check (54.9%), rather than during evaluation of symptoms (45.1%) (P<0.001). In cohort 1, 48.1% of patients in falls to BCLC stage C which decreased to 29.6% in cohort 2 with increase in the proportion of BCLC stage A from 14.4% to 39.5% (P<0.001). No changes was observed for the rate of surgical resection between two cohorts with BCLC stage A (26.1% vs. 26.0%) and B (13.1% vs. 18.3%). However, TACE was most frequently performed in the cohort 1 (40.6%) while RFA was more frequently performed in cohort 2 (55.1%) with BCLC A HCC. Survival significantly improved in cohort 2 compared to cohort 1 (65.0 vs 7.9 months, P<0.001), remarkably in BCLC stage A (93.8 vs 43.9 months, P<0.001) and BCLC stage B (47.1 vs 21.3 months, P<0.001). In univariate analysis, type of cohort, age, gender, etiology, MELD score, route of HCC diagnosis, BCLC stage, and treatment modalities were significantly associated with survival. On multivariate analysis, MELD score, route of HCC diagnosis, BCLC stage, and the HCC treatment modalities were the only significant factors. Conclusions There are changes in the time and route of HCC diagnosis, state of HCC and survival during 20 years, most probably owing to antiviral treatment for CHB, generalization of medical check-up and HCC surveillance program.