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Karademir. Hepatoma Res 2018;4:58 I http://dx.doi.org/10.20517/2394-5079.2018.40 Page 9 of 18

Table 7. Chinese University Prognostic Index [9]
Scores
TNM stage
I and II -3
IIIa and IIIb -1
IVa and IVb 0
Asymptomatic disease on presentation -4
Ascites 3
Alpha-fetoprotein (≥ 500 ng/mL) 2
Total bilirubin (μmol/L)
< 34 0
34-51 3
≥ 52 4
Alkaline phosphatase (≥ 200 units/L) 3

The prognostic factors used in this system are readily available in daily clinical practice and the score is
determined based on the estimated Cox regression coefficient. However, CUPI was derived from a cohort
of HCC patients primarily with HBV infection (79% of the whole cohort). Thus, this system may not be
suitable for application in Western populations with predominant HCV infection or a history of alcohol
abuse. Another criticism levelled at CUPI was that only a small proportion of early-stage HCC patients
have received surgery (10.4%). Most of the patients in this cohort were in late stage and received only
[9]
supportive care (58.4%) . Therefore, this system may not be preferred for assessing patients who undergo
curative treatment, such as surgical resection or radiofrequency ablation (RFA). In comparison to other
staging systems, the CUPI has not shown a prognostic advantage over other systems and has failed to
gain widespread acceptance and usage. Moreover, though it is mainly used in Asian populations with a
background of hepatitis B, still there is no evidence that CUPI has universal applicability among liver cancer
patients of other races.

Tokyo score
[11]
Tokyo score was proposed by Tateishi et al. in 2005 based on a retrospective analysis of 403 HCC
patients treated by percutaneous ablation at the University of Tokyo and was validated in 203 HCC patients
who underwent surgery resection at the same institution. The main purpose of this study is to develop
new prognostic scoring system for patients at early-stage who are candidates for radical therapy, such as
percutaneous ablation or surgical resection. They used only serum albumin and bilirubin values as indicators
of remnant liver function. This system consists of four factors: tumor size, number of tumor nodules, serum
albumin and bilirubin which can be easily obtained from daily laboratory data or images before surgery
[Table 8]. Scores are assigned to each of the four variables according to the estimated regression coefficient.
Patients have total scores ranging from 0 to 6, Tokyo-0 patient having a better prognosis than those patients
with Tokyo-6 (five-year survival rates of 78.7% vs. 14.3%, respectively). In validation study, Tokyo staging
[11]
system has shown to have a predictive ability equal to CLIP and better than BCLC classification .

Tokyo score is useful in Japanese patients with early stage HCC requiring radical therapy but not suitable
for use in patients with advanced stages of disease. Thus, its validation is required in Western population.
Performance status and cancer-related symptoms have not been included in Tokyo score because most HCC
patients in Japan were diagnosed at an early, asymptomatic stage of the disease due to nationwide screening
program for viral hepatitis and surveillance in high-risk groups for HCC.

Bilirubin-albumin-AFPL3-AFP-DCP score
[60]
Bilirubin-albumin-AFPL3-AFP-DCP (BALAD) score is proposed by Toyoda et al. in 2006 for the purpose
of providing a simple and objective staging system that requires no imaging studies, pathological or clinical