Proposal of a modified cancer of the liver Italian program staging system based on the model for end-stage liver disease for patients with hepatocellular carcinoma undergoing loco-regional therapy

BACKGROUND: The Cancer of Liver Italian Program (CLIP) system was suggested as the primary staging system for hepatocellular carcinoma (HCC). The model for end-stage liver disease (MELD) is a better prognostic predictor for cirrhotic patients compared to Child-Turcotte-Pugh (CTP) system, which is a parameter used in the CLIP model. AIM: To investigate the performance of the modified MELD-based CLIP systems. METHODS: The CTP class in the CLIP model was replaced with MELD score (< 10, 10-14, > 14; modified CLIP-1), or additional 1 or 2 points were given to patients with MELD score 10-14 or > 14, respectively (modified CLIP-2). The modified CLIP systems were compared with the original system in 343 HCC patients undergoing loco-regional therapy. RESULTS: The original CLIP score in all patients was 1.2 +/- 1.1 (range 0-5), compared with 1.4 +/- 1.2 (range 0-5) for modified CLIP-1 and 1.7 +/- 1.4 (range 0-6) for modified CLIP-2 models (p < 0.001). Using mortality as the endpoint, the area under receiver operating characteristic curve for modified CLIP-2 system was 0.858 compared with 0.812 for modified CLIP-1 (p = 0.013) and 0.782 for original CLIP system (p < 0.001) at 12 months; the area was 0.879, 0.830, and 0.762, respectively (p all < 0.001) at 24 months. Survival analysis showed that the modified CLIP systems had a better long-term discriminatory ability for different score groups. CONCLUSIONS: The CLIP model is useful to predict the outcome in HCC patients undergoing loco-regional therapy. The MELD-based modified CLIP systems may have a better predictive ability than the original model for cancer staging.