Prognostic stratification and nomogram for survival prediction in hepatocellular carcinoma patients treated with radiotherapy for lymph node metastasis

Objective: To establish a prognostic model for overall survival prediction in patients with hepatocellular carcinoma (HCC) treated with external beam radiotherapy (RT) for lymph node (LN) metastasis. Methods: 105 patients with HCC underwent RT for LN metastasis. The median age, biologically effective RT dose and follow-up period were 60 years, 59Gy10 and 5.7 months, respectively. 51 patients had symptoms related to LN metastasis. Results: The median survival (MS) was 5.8 months for all patients. For patients with LN-related symptoms, MS was 3.8 months compared with 10.7 months for those without LN-related symptoms. On multivariate analysis of pre-RT factors, symptoms related to LN metastasis [hazard ratio (HR) 2.93], Child-Pugh Class B-C (HR 2.77), uncontrolled intrahepatic disease (HR 2.74) and non-nodal distant metastasis (HR 1.62) were significantly poor prognostic factors for survival (all p<0.05). Prognostic grouping into three groups by the number of risk factors also had a significant predictive value for survival, with patients having 0, 1, 2 and 3-4 risk factors demonstrating MS of 18.0, 11.7, 5.7 and 3.0 months, respectively (p<0.001). A clinical nomogram based on the four prognostic factors was formulated and demonstrated good accuracy for predicting 6-month survival with a concordance index of 0.77. Conclusion: In a heterogeneous group of patients with HCC treated with RT for LN metastasis, the presence of LN-related symptoms was highly associated with poor survival. The prognostic grouping and nomogram developed by the present study can be effectively used for the prediction of survival. Advances in knowledge: Patients treated with RT for LN metastases harbour various clinical features. Prognostic model and nomogram can help in predicting survival in these patients.