• Conflict of interest: Nothing to report.


We appreciate the comments of Huo and Huang related to our recent publication. Huo and Huang are not in full agreement with our conclusions. First, Huo and Huang misunderstood that the majority (96%) of the patients in our study had undergone radical treatment (resection or loco-regional therapy), suggesting that most of them belonged to an early or intermediate stage. However, the potentially curative (radical) treatments such as resection or percutaneous ablation were performed only in 45% (2,023 of 4,525) of the patients. Transcatheter arterial chemoembolization (TACE) was performed on 39% of the patients. Patients who received TACE, a noncurative modality, are categorized mostly into the advanced stage and partly into the intermediate stage. In that sense, Huo and Huang's claim is not correct.

Second, it is incorrect to state that the JIS score is similar to the BCLC system. There is a difference between a prognostic staging system and a treatment allocation staging system. The CLIP score and the JIS score were developed for the prediction of prognosis in patients with HCC. In contrast, BCLC staging was developed for the adequate allocation of the HCC patients into given treatment modalities.

Third, Huo and Huang state that the JIS system is only meaningful in the population that is predominantly treated with radical therapy. As already noted, 55% of our patient population was allocated to the relatively conservative treatment modalities such as TACE, chemolipiodolization, or no treatment; therefore, their statement is again out of focus. Conversely, the JIS score works well in the stratification of HCC patients from early stage to advanced stage. The JIS system is useful not only in selected patients but also the entire spectrum, from early to end-stage HCC patients.

We agree with Huo and Huang that the JIS system works well in areas where HCC is diagnosed at a relatively early stage, whereas the CLIP system would only prevail when patients predominantly belonged to an intermediate or late stage, a condition in which aggressive therapy is less likely. In that sense, tumor-node-metastasis (TNM) stage by the Liver Cancer Study Group of Japan1–3 is fairly important because the cutoff size of 2 cm for the nodule is crucial for curative treatment. Microscopic portal venous invasion and intrahepatic metastasis are already noted even in the small HCC nodules less than 2 cm in diameter in 27% and 10% of cases, respectively.4 Actually, until 10 years ago the CLIP and JIS scores had an identical prognostic significance among Japanese patients, but over the past 10 years the JIS score is apparently superior to CLIP score (M. Kudo et al., unpublished data).

Masatoshi Kudo*, * Department of Gastroenterology and Hepatology, Kinki University School of Medicine, Osaka, Japan.