Staging systems: Is there a surgical staging and a medical one? Hepatologist's perspective

Clinical staging systems for cancer provide guidelines for patient assessments and therapeutic decisions. Furthermore, appropriate staging is essential for objective comparison between the outcomes of different treatments, including clinical trials. While the prognosis of most solid tumors is generally dependent on tumor stage at presentation, prediction of prognosis in hepatocellular carcinoma (HCC) patients is more complicated because underlying liver function also affects patient survival. The Okuda classification and the pathologic tumor-node-metastasis classification are most commonly used internationally, but each has its own limitation. Several new staging systems for HCC have recently been reported from Italy, Japan, and Spain. Most prognostic models consist of parameters reflecting tumor stage and liver function reservoir, which were selected based on analyses of large series of HCC patients. Ideally, staging systems should be applicable to any HCC patient. However, each existing staging system may have been characterized by the patient population based on which it was constructed. For practical purposes, staging systems should be simple and based on data that are easily obtainable. Consensus is yet to be achieved on the optimal staging system for HCC that assures progress in the development of novel therapies.