Over the past decade, non-surgical therapies for hepatocellular carcinoma (HCC) occurring on a background of cirrhosis have been established as effective. Hepatic arterial chemoembolisation has a proven survival advantage in selected patient groups,^1,2 and there is now strong evidence that ablative therapies, both percutaneous alcohol injection³ and radiofrequency ablation,⁴ have survival benefit. In addition, HCC incidence is increasing in the Western world, mainly due to the hepatitis C epidemic and this cancer now has an increasing impact on health services.

A further change in the clinical setting in which we encounter HCC has occurred. The advent of ablative therapy for HCC, which can destroy tumour nodules up to approximately 5 cm in diameter, has focused the need for detection of tumours at an early stage in cirrhotic patients and has led to the widespread use of screening in most of the world. There is no doubt that screening using ultrasound and α fetoprotein will detect HCC at a smaller size.⁵ This has produced the need for new prognostic models given that the initial Okuda system⁶ was developed some 30 years ago when the size of HCCs at presentation was substantially larger than today.

Thus prognostic models are important from both a clinical perspective, of being able to give patients and their relatives accurate information on survival, and from a research perspective, to assess outcome of new therapies to help define prognosis as accurately as possible. A number of prognostic models for HCC have been developed. All models have been established in patient cohorts and validated in other cohorts. All available models have established two key factors influencing outcome: how good is the underlying liver function and how extensive is the tumour.

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