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Page 12 of 18 Karademir. Hepatoma Res 2018;4:58 I http://dx.doi.org/10.20517/2394-5079.2018.40

Table 13. MESIAH Score [12]
MESIAH Score
- 0.232* (age in decades)
+ 0.099* (MELD)
- 0.391* (serum albumin level)
+ 0.290* (tumor size)
+ 0.153* (tumor number)
+ 1.122* (vascular invasion)
+ 1.130* (extrahepatic metastasis)
+ 0.082* (serum alpha-fetoprotein level)
+ 1
MESIAH: model to estimate survival in ambulatory HCC; MELD: model for end-stage liver disease

was constructed based on the results for a cohort of HCC patients with predominant HBV infection (HBV
51%, HCV 27%). Therefore, it needs to be externally validated in Western population.

Model to estimate survival in ambulatory HCC patients score
The model to estimate survival in ambulatory HCC patients score (MESIAH score) was developed by Yang et al. from
[12]
the Mayo group, in 2012. MESIAH score is derived from a cohort of 477 HCC patients treated at the Mayo
Clinic [derivation cohort (DC)] and 904 HCC patients treated at a Korean institution [validation cohort
(VC)]. Validation was done using a data set that is racially, geographically, chronologically and diagnostically
disparate from the derivation set. The DC differed from VC with regard to the underlying liver disease
(DC = HCV 81% vs. VC = HBV 75%) and treatment modality (DC = transplantation 31%, resection 17%,
TACE 25% vs. VC= resection 13%, TACE 57%). The authors identified independent predictors for survival
in a multivariate Cox model [age, model for end-stage liver disease (MELD) score, serum albumin level,
tumor size, tumor number, vascular invasion and extrahepatic metastasis], thus creating a new risk score
[Table 13]. The authors include MELD as an indicator of liver disease severity. MELD has been shown to be
a useful measure of hepatic insufficiency since it was adopted as a standard to determine organ allocation
[64]
priorities among liver transplant candidates in the USA and elsewhere , MELD is consisted of only
laboratory variables (bilirubin, INR, creatinine) which are widely available and reproducible. The prognostic
value of the MESIAH score was confirmed in the VC. The predictive accuracy of MESIAH is highly stable,
irrespective of the underlying liver disease and/or treatment modality. More recently, the same group
validated this score in another cohort of 1969 HCC patients with predominant HBV infection (74.6%) treated
at a Korean institution . The discriminatory ability of the MESIAH score is better than that of the BCLC,
[65]
CLIP, JIS and Tokyo. However, calculating the MESIAH score is somewhat complicated in daily clinical
practice. Considering the advantages of superior predictive accuracy and objectivity and reproducibility of
the prognostic factors, independent of the underlying liver disease and treatment modality, the MESIAH
score is one of the most promising staging systems for evaluating HCC patients.

Hong Kong Liver Cancer classification
[4]
The Hong Kong Liver Cancer (HKLC) classification was developed by a Hong Kong group in 2014 . Like the
BCLC, HKLC links HCC stages to treatment options. This system is based on four established prognostic
factors: ECOG PS, Child-Pugh grade, liver tumor status and presence of extrahepatic vascular invasion
or metastasis [Figure 2]. HKLC was derived from the results of a cohort of 3856 HCC patients primarily
with HBV infection treated at single institution. Based on these prognostic factors, patients are classified
in five main groups and nine subgroups with distinct survival outcomes. In the authors’ analysis, HKLC
classification exhibits better prognostic value than the BCLC classification. Regarding to problematic issues
of BCLC such as heterogeneity of the stages B and C, and rigidity of treatment allocation, HKLC is able
to better stratify patients in these stages into distinct groups with better survival outcomes based on more
aggressive treatment recommendations than that observed in the BCLC treatment algorithm. Interestingly,