Nomogram-based prognostic stratification for patients with large hepatocellular carcinoma: a population study of SEER database and a Chinese cohort

Background: Large hepatocellular carcinoma (HCC) with a diameter >= 5 cm remains a significant challenge of poor survival and raises the need for prognosis evaluation. This study aimed to develop and validate a nomogram-based prognostic stratification to assess overall survival (OS) of patients with large HCC. Methods: Data of patients with large HCC were retrospectively collected from the Surveillance, Epidemiology, and End Results (SEER) database and our hospital, and were divided into the training cohort, internal validation cohort and external validation cohort. Cox analysis was performed to identify independent prognostic factors for the construction of nomogram in training cohort. The predictive ability of the nomogram was validated compared with the tumor node metastasis (TNM) classification staging system. Furthermore, prognostic stratification system based on nomogram was developed. Results: Independent prognostic factors including histological grade, T stage, M stage, alpha fetoprotein (AFP), fibrosis score and surgery, were incorporated to construct nomogram. C-indexes of nomogram were 0.730, 0.726 and 0.724 in the training, internal and external validation cohorts, respectively. Importantly, nomogram harbored a superior discrimination and clinical benefit than the TNM staging system. Nomogram-based prognostic stratification divided patients into three groups: 345-414 (low-risk group), 415-460 (medium-risk group) and 461-513 (high-risk group). As shown in Kaplan-Meier curves, there were significant differences in OS among low-, medium- and high-risk groups (P<0.01). Conclusions: Nomogram showed a superior prognostic predictive ability compared with the TNM staging system. The prognostic stratification serves as a valuable tool to assist clinicians on the selection of optimal treatment method and follow-up plan, particularly for the high-risk population