Toronto HCC Risk Index: A validated scoring system to predict 10-year risk of HCC in patients with cirrhosis

Suraj A. Sharma, Matthew Kowgier, Bettina E. Hansen, Willem Pieter Brouwer, Raoel Maan, David Wong, Hemant Shah, Korosh Khalili, Colina Yim, E. Jenny Heathcote, Harry L. A. Janssen, Morris Sherman, Gideon Hirschfield, Jordan J. Feld

Research output: Contribution to journalArticlepeer-review

36 Citations (Scopus)
1157 Downloads (Pure)


Background: Current guidelines recommend biannual surveillance for hepatocellular carcinoma (HCC) in all patients with cirrhosis, regardless of etiology. However, HCC incidence is not well established for many causes of cirrhosis. Aim: To assess the disease-specific incidence of HCC in a large cohort of patients with cirrhosis and to develop a scoring system to predict HCC risk. Methods: A derivation cohort of patients with cirrhosis diagnosed by biopsy or non-invasive measures was identified through retrospective chart review. The disease-specific incidence of HCC was calculated according to etiology of cirrhosis. Factors associated with HCC were identified through multivariable Cox regression and used to develop a scoring system to predict HCC risk. The scoring system evaluated in an external cohort for validation. Results: Of 2,079 patients with cirrhosis and ≥6 months follow-up, 226 (10.8%) developed HCC. The 10-year cumulative incidence of HCC varied by etiologic category from 22% in patients with viral hepatitis, to 16% in those with steatohepatitis and 5% in those with autoimmune liver disease (p<0.001). By multivariable Cox regression, age, sex, etiology and platelets were associated with HCC. Points were assigned in proportion to each hazard ratio to create the Toronto HCC Risk Index (THRI). The 10-year cumulative HCC incidence was 3%, 10% and 32% in the low (<120 points) medium (120-240) and high (>240) risk groups respectively, values that remained consistent after internal validation. External validation was performed on a cohort of patients with PBC, HBV and HCV cirrhosis (n= 1,144) with similar predictive ability (Harrell’s c-statistic 0.77) in the validation and derivation cohorts. Conclusion: HCC incidence varies markedly by etiology of cirrhosis. The THRI, using readily available clinical and laboratory parameters, has good predictive ability for HCC in patients with cirrhosis, and has been validated in an external cohort. This risk score may help to guide recommendations regarding HCC surveillance among patients with cirrhosis.
Original languageEnglish
JournalJournal of Hepatology
Early online date24 Aug 2017
Publication statusE-pub ahead of print - 24 Aug 2017


  • cirrhosis
  • hepatocellular carcinoma
  • HCC
  • Toronto hepatoma risk index (THRI)
  • cumulative incidence


Dive into the research topics of 'Toronto HCC Risk Index: A validated scoring system to predict 10-year risk of HCC in patients with cirrhosis'. Together they form a unique fingerprint.

Cite this