A Comparative Study of Albumin-Bilirubin Score with Child-Pugh Score, Model for End-Stage Liver Disease Score and Indocyanine Green R15 in Predicting Posthepatectomy Liver Failure for Hepatocellular Carcinoma Patients

Predicting post-hepatectomy liver failure using a nomogram based on portal vein width, inflammatory indices, and the albumin-bilirubin score

BACKGROUND

Post-hepatectomy liver failure (PHLF) after liver resection is one of the main complications causing postoperative death in patients with hepatocellular carcinoma (HCC). It is crucial to help clinicians identify potential high-risk PHLF patients as early as possible through preoperative evaluation.

AIM

To identify risk factors for PHLF and develop a prediction model.

METHODS

This study included 248 patients with HCC at The Second Affiliated Hospital of Air Force Medical University between January 2014 and December 2023; these patients were divided into a training group (n = 164) and a validation group (n = 84) via random sampling. The independent variables for the occurrence of PHLF were identified by univariate and multivariate analyses and visualized as nomograms. Ultimately, comparisons were made with traditional models via receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA).

RESULTS

In this study, portal vein width [odds ratio (OR) = 1.603, 95%CI: 1.288-1.994, P ≤ 0.001], the preoperative neutrophil-to-lymphocyte ratio (NLR) (OR = 1.495, 95%CI: 1.126-1.984, P = 0.005), and the albumin-bilirubin (ALBI) score (OR = 8.868, 95%CI: 2.144-36.678, P = 0.003) were independent risk factors for PHLF. A nomogram prediction model was developed using these factors. ROC and DCA analyses revealed that the predictive efficacy and clinical value of this model were better than those of traditional models.

CONCLUSION

A new Nomogram model for predicting PHLF in HCC patients was successfully established based on portal vein width, the NLR, and the ALBI score, which outperforms the traditional model.

Chronic Hepatitis C Infection Treated with Direct-Acting Antiviral Agents and Occurrence/Recurrence of Hepatocellular Carcinoma: Does It Still Matter?

Hepatitis C virus (HCV) infection is a significant risk factor for liver cirrhosis and hepatocellular carcinoma (HCC). Traditionally, the primary prevention strategy for HCV-associated HCC has focused on removing infection through antiviral regimes. Currently, highly effective direct-acting antivirals (DAAs) offer extraordinary success across all patient categories, including cirrhotics. Despite these advancements, recent studies have reported that even after sustained virologic response (SVR), individuals with advanced liver disease/cirrhosis at the time of DAA treatment may still face risks of HCC occurrence or recurrence. Based on this premise, this review tries to shed light on the multiple mechanisms that establish a tumorigenic environment, first, during chronic HCV infection and then, after eventual viral eradication by DAAs. Furthermore, it reviews evidence reported by recent observational studies stating that the use of DAAs is not associated with an increased risk of HCC development but rather, with a significantly lower chance of liver cancer compared with DAA-untreated patients. In addition, it seeks to provide some practical guidance for clinicians, helping them to manage HCC surveillance of patients who have achieved SVR with DAAs.

A Simple Prognostic Scoring System for Hepatocellular Carcinoma Treated with DEB-TACE

Objective

To develop a simple and effective prognostic scoring system to predict the efficacy of drug-eluting bead-transcatheter arterial chemoembolization (DEB-TACE) in the treatment of hepatocellular carcinoma (HCC).

Methods

Data were retrospectively collected from 230 patients with HCC who received DEB-TACE treatment at six medical centers between January 2019 and December 2022. We developed a predictive score based on independent risk factors for overall survival (OS), validated the model using a validation cohort, and compared its prognostic accuracy with commonly used HCC staging systems.

Results

The number of tumors, albumin-bilirubin levels, alpha-fetoprotein levels, and portal vein thrombus grade were identified as independent factors influencing OS. Based on these factors, we established the DEB-TACE treatment of HCC (DTH) scoring system. The DTH score correlated well with OS, which decreased as the DTH score increased. According to the DTH score, patients were categorized into three risk groups: low-risk (DTH-A, 0-4 points), medium-risk (DTH-B, 5-6 points), and high-risk (DTH-A, 7 points). The OS of each risk group was 18.73±0.62 months, 12.73±0.10 months, and 6.93±0.19 months, respectively (p<0.001). The external cohort validation confirmed the accuracy of the DTH score, demonstrating superior predictive performance compared to other commonly used HCC scoring systems.

Conclusion

The DTH-HCC scoring system effectively predicts the outcomes of HCC patients undergoing DEB-TACE as initial treatment. This model can aid in the initial planning and decision-making process for DEB-TACE treatment in HCC patients.

Development and validation of prealbumin-bilirubin score (preALBI score) for predicting long-term survival after hepatectomy for hepatocellular carcinoma: A multicenter analysis versus ALBI score

BACKGROUND

The Albumin-Bilirubin (ALBI) score, widely used in predicting long-term prognosis for patients with hepatocellular carcinoma (HCC), has limitations due to serum albumin variability. This study aimed to develop and validate the Prealbumin-Bilirubin (preALBI) score as a reliable alternative.

METHODS

A multicenter cohort of HCC patients who underwent hepatectomy was randomly divided into the training and validation cohorts. The preALBI score was developed using Cox regression models within the training cohort, incorporating serum prealbumin and bilirubin levels as crucial determinants. The survival predictive accuracy was evaluated and compared between the preALBI score with two other staging systems, including the ALBI score and the Child-Pugh grade.

RESULTS

A total of 2409 patients were enrolled. In the training cohort, the preALBI score demonstrated superior performance in predicting long-term survival after hepatectomy. The preALBI score was associated with the best monotonicity of gradients (linear trend χ2: 72.84) and homogeneity (likelihood ratio χ2: 74.69), and the highest discriminatory ability (the areas under curves for 1-, 3-, and 5-year mortality: 0.663, 0.654, and 0.644, respectively). In addition, the preALBI was the most informative staging system in predicting survival (Akaike information criterion: 11325.65).The results remained consistent in both training and validation cohorts, indicating its reliable performance across different populations.

CONCLUSION

The preALBI score, leveraging the stability of prealbumin, represents a promising tool for better patient stratification, providing more accurate prognostic predictions than the ALBI score and the Child-Pugh grade.

Albumin-bilirubin grade as a predictor of survival in hepatocellular carcinoma patients with thrombocytopenia

BACKGROUND

The models for assessing liver function, mainly the Child-Pugh (CP), albuminbilirubin (ALBI), and platelet-ALBI (PALBI) classifications, have been validated for use in estimating the prognosis of hepatocellular carcinoma (HCC) patients. However, thrombocytopenia is a common finding and may influence the prognostic value of the three models in HCC.

AIM

To investigate and compare the prognostic performance of the above three models in thrombocytopenic HCC patients.

METHODS

A total of 135 patients with thrombocytopenic HCC who underwent radical surgery were retrospectively analyzed. Preoperative scores on the CP, ALBI and PALBI classifications were estimated accordingly. Kaplan-Meier curves with log-rank tests and Cox regression models were used to explore the significant factors associated with overall survival (OS) and recurrence-free survival (RFS).

RESULTS

The preoperative platelet counts were significantly different among the CP, ALBI and PALBI groups. After a median follow-up of 28 mo, 39.3% (53/135) of the patients experienced postoperative recurrence, and 36.3% (49/135) died. Univariate analysis suggested that α-fetoprotein levels, tumor size, vascular invasion, and ALBI grade were significant predictors of OS and RFS. According to the multivariate Cox regression model, ALBI was identified as an independent prognostic factor. However, CP and PALBI grades were not statistically significant prognostic indicators.

CONCLUSION

The ALBI grade, rather than CP or PALBI grade, is a significant prognostic indicator for thrombocytopenic HCC patients.

Preliminary exploration of hepatic parenchymal near-infrared fluorescence imaging technique via retrograde biliary approach: a feasibility study (with video)

This paper explores the feasibility and principle of hepatic parenteral fluorescence imaging technology after retrograde injection of indocyanine green (ICG) through endoscopic nasobiliary drainage (ENBD). The data were collected from 53 patients with cholecystolithiasis and choledocholithiasis, from October 2022 to March 2023, diagnosed by fluorescence imaging technique retrograde biliary approach (FIT-RB). We divided the patients into two groups according to the features of liver parenchyma, the poor group (n = 34, including scattered or no imaging) and the good group (n = 19, regular uniform imaging). We compared and analyzed the perioperative results of the two groups and explored the influencing factors of the success of FIT-RB and the ICG concentration suitable for this imaging technique. The good imaging rate of the 53 enrolled cases was 35.8%. The bilirubin level before ENBD and laparoscopic cholecystectomy in the poor group was significantly higher than that in the good group (P < 0.001). The proportion of higher ICG concentrations (0.5 mg/mL) was significantly higher in the good group (P = 0.028). Our results demonstrated that the success rate of good imaging was 4.53 times higher than that of low-dose ICG (0.125 or 0.25 mg/L) cases at 0.5 mg/ml of ICG. The level of total bilirubin and direct bilirubin were negatively correlated with the imaging effect, and total bilirubin and direct bilirubin levels were important predictors of the efficacy of FIT-RB. FIT-RB is safe and feasible in patients with low site bilirubin levels. An ICG concentration of 0.5 mg/ml may be ideal for implementing this technique.

An Interpretable Radiomics Model Based on Two-Dimensional Shear Wave Elastography for Predicting Symptomatic Post-Hepatectomy Liver Failure in Patients with Hepatocellular Carcinoma

OBJECTIVE

The aim of this study was to develop and validate an interpretable radiomics model based on two-dimensional shear wave elastography (2D-SWE) for symptomatic post-hepatectomy liver failure (PHLF) prediction in patients undergoing liver resection for hepatocellular carcinoma (HCC).

METHODS

A total of 345 consecutive patients were enrolled. A five-fold cross-validation was performed during training, and the models were evaluated in the independent test cohort. A multi-patch radiomics model was established based on the 2D-SWE images for predicting symptomatic PHLF. Clinical features were incorporated into the models to train the clinical-radiomics model. The radiomics model and the clinical-radiomics model were compared with the clinical model comprising clinical variables and other clinical predictive indices, including the model for end-stage liver disease (MELD) score and albumin-bilirubin (ALBI) score. Shapley Additive exPlanations (SHAP) was used for post hoc interpretability of the radiomics model.

RESULTS

The clinical-radiomics model achieved an AUC of 0.867 (95% CI 0.787-0.947) in the five-fold cross-validation, and this score was higher than that of the clinical model (AUC: 0.809; 95% CI: 0.715-0.902) and the radiomics model (AUC: 0.746; 95% CI: 0.681-0.811). The clinical-radiomics model showed an AUC of 0.822 in the test cohort, higher than that of the clinical model (AUC: 0.684, p = 0.007), radiomics model (AUC: 0.784, p = 0.415), MELD score (AUC: 0.529, p < 0.001), and ALBI score (AUC: 0.644, p = 0.016). The SHAP analysis showed that the first-order radiomics features, including first-order maximum 64 × 64, first-order 90th percentile 64 × 64, and first-order 10th percentile 32 × 32, were the most important features for PHLF prediction.

CONCLUSION

An interpretable clinical-radiomics model based on 2D-SWE and clinical variables can help in predicting symptomatic PHLF in HCC.

Current status of preoperative risk assessment for posthepatectomy liver failure in patients with hepatocellular carcinoma

Liver resection is an effective therapeutic option for patients with hepatocellular carcinoma. However, posthepatectomy liver failure (PHLF) remains a major cause of hepatectomy-related mortality, and the accurate prediction of PHLF based on preoperative assessment of liver functional reserve is a critical issue. The definition of PHLF proposed by the International Study Group for Liver Surgery has gained acceptance as a standard grading criterion. Liver function can be estimated using a variety of parameters, including routine blood biochemical examinations, clinical scoring systems, dynamic liver function tests, liver stiffness and fibrosis markers, and imaging studies. The Child-Pugh score and model for end-stage liver disease scores are conventionally used for estimating liver decompensation, although the alternatively developed albumin-bilirubin score shows superior performance for predicting hepatic dysfunction. Indocyanine green clearance, a dynamic liver function test mostly used in Japan and other Asian countries, serves as a quantitative estimation of liver function reserve and helps determine indications for surgical procedures according to the estimated risk of PHLF. In an attempt to improve predictive accuracy, specific evaluation of liver fibrosis and portal hypertension has gained popularity, including liver stiffness measurements using ultrasonography or magnetic resonance elastography, as well as noninvasive fibrosis markers. Imaging modalities, including Tc-99m-labeled galactosyl serum albumin scintigraphy and gadolinium-enhanced magnetic resonance imaging, are used for preoperative evaluation in combination with liver volume. This review aims to provide an overview of the usefulness of current options for the preoperative assessment of liver function in predicting PHLF.

CT-derived extracellular volume and liver volumetry can predict posthepatectomy liver failure in hepatocellular carcinoma

OBJECTIVES

Posthepatectomy liver failure (PHLF) is a severe complication of liver resection. We aimed to develop and validate a model based on extracellular volume (ECV) and liver volumetry derived from computed tomography (CT) for preoperative predicting PHLF in resectable hepatocellular carcinoma (HCC) patients.

METHODS

A total of 393 resectable HCC patients from two hospitals were enrolled and underwent multiphasic contrast-enhanced CT before surgery. A total of 281 patients from our hospital were randomly divided into a training cohort (n = 181) and an internal validation cohort (n = 100), and 112 patients from another hospital formed the external validation cohort. CT-derived ECV was measured on nonenhanced and equilibrium phase images, and liver volumetry was measured on portal phase images. The model is composed of independent predictors of PHLF. The under the receiver operator characteristic curve (AUC) and calibration curve were used to reflect the predictive performance and calibration of the model. Comparison of AUCs used the DeLong test.

RESULTS

CT-derived ECV, measured future liver remnant (mFLR) ratio, and serum albumin were independent predictors for PHLF in resectable HCC patients. The AUC of the model was significantly higher than that of the ALBI score in the training cohort, internal validation cohort, and external validation cohort (all p < 0.001). The calibration curve of the model showed good consistency in the training cohort and the internal and external validation cohorts.

CONCLUSIONS

The novel model contributes to the preoperative prediction of PHLF in resectable HCC patients.

CRITICAL RELEVANCE STATEMENT

The novel model combined CT-derived extracellular volume, measured future liver remnant ratio, and serum albumin outperforms the albumin-bilirubin score for predicting posthepatectomy liver failure in patients with resectable hepatocellular carcinoma.

KEY POINTS

• CT-derived ECV correlated well with the fibrosis stage of the background liver. • CT-derived ECV and mFLR ratio were independent predictors for PHLF in HCC. • The AUC of the model was higher than the CT-derived ECV and mFLR ratio. • The model showed a superior predictive performance than that of the ALBI score.

Using AI and Gd-EOB-DTPA-enhanced MR imaging to assess liver function, comparing the MELIF score with the ALBI score

Monitoring disease progression is particularly important for determining the optimal treatment strategy in patients with liver disease. Especially for patients with diseases that have a reversible course, there is a lack of suitable tools for monitoring liver function. The development and establishment of such tools is very important, especially in view of the expected increase in such diseases in the future. Image-based liver function parameters, such as the T1 relaxometry-based MELIF score, are ideally suited for this purpose. The determination of this new liver function score is fully automated by software developed with AI technology. In this study, the MELIF score is compared with the widely used ALBI score. The ALBI score was used as a benchmark, as it has been shown to better capture the progression of less severe liver disease than the MELD and Child‒Pugh scores. In this study, we retrospectively determined the ALBI and MELIF scores for 150 patients, compared these scores with the corresponding MELD and Child‒Pugh scores (Pearson correlation), and examined the ability of these scores to discriminate between good and impaired liver function (AUC: MELIF 0.8; ALBI 0.77) and to distinguish between patients with and without cirrhosis (AUC: MELIF 0.83, ALBI 0.79). The MELIF score performed more favourably than the ALBI score and may also be suitable for monitoring mild disease progression. Thus, the MELIF score is promising for closing the gap in the available early-stage liver disease monitoring tools (i.e., identification of liver disease at a potentially reversible stage before chronic liver disease develops).

ICG fluorescence imaging technology in laparoscopic liver resection for primary liver cancer: A meta-analysis

OBJECTIVE

To study the value of ICG molecular fluorescence imaging in laparoscopic hepatectomy for PLC.

METHODS

CNKI, WD, VIP.com, PM, CL and WOS databases were selected to search for literature on precise and traditional hepatectomy for the treatment of PLC.

RESULTS

A total of 33 articles were used, including 3987 patients, 2102 in precision and 1885 in traditional. Meta showed that the operation time of precision was longer, while IBV, HS, PLFI, ALT, TBil, ALB, PCR, PROSIM, RMR and 1-year SR had advantages.

CONCLUSION

Hepatectomy with the concept of PS is a safe and effective method of PLC that can reduce the amount of IB, reduce surgery, reduce PC and improve prognosis and quality of life.

A radiomics model based on preoperative gadoxetic acid-enhanced magnetic resonance imaging for predicting post-hepatectomy liver failure in patients with hepatocellular carcinoma

Background

Post-hepatectomy liver failure (PHLF) is a fatal complication after liver resection in patients with hepatocellular carcinoma (HCC). It is of clinical importance to estimate the risk of PHLF preoperatively.

Aims

This study aimed to develop and validate a prediction model based on preoperative gadoxetic acid-enhanced magnetic resonance imaging to estimate the risk of PHLF in patients with HCC.

Methods

A total of 276 patients were retrospectively included and randomly divided into training and test cohorts (194:82). Clinicopathological variables were assessed to identify significant indicators for PHLF prediction. Radiomics features were extracted from the normal liver parenchyma at the hepatobiliary phase and the reproducible, robust and non-redundant ones were filtered for modeling. Prediction models were developed using clinicopathological variables (Clin-model), radiomics features (Rad-model), and their combination.

Results

The PHLF incidence rate was 24% in the whole cohort. The combined model, consisting of albumin-bilirubin (ALBI) score, indocyanine green retention test at 15 min (ICG-R15), and Rad-score (derived from 16 radiomics features) outperformed the Clin-model and the Rad-model. It yielded an area under the receiver operating characteristic curve (AUC) of 0.84 (95% confidence interval (CI): 0.77-0.90) in the training cohort and 0.82 (95% CI: 0.72-0.91) in the test cohort. The model demonstrated a good consistency by the Hosmer-Lemeshow test and the calibration curve. The combined model was visualized as a nomogram for estimating individual risk of PHLF.

Conclusion

A model combining clinicopathological risk factors and radiomics signature can be applied to identify patients with high risk of PHLF and serve as a decision aid when planning surgery treatment in patients with HCC.

The value of intraoperative dynamic liver function test ICG in predicting postoperative complications in patients undergoing staged hepatectomy: a pilot study

PURPOSE

To assess the predictive value of intraoperative indocyanine green (ICG) test in patients undergoing staged hepatectomy.

METHODS

We analyzed intraoperative ICG measurements of future liver remnant (FLR), preoperative ICG, volumetry, and hepatobiliary scintigraphy in 15 patients undergoing associated liver partition and portal vein ligation for staged hepatectomy (ALPPS). Main endpoints were the correlation of intraoperative ICG values to postoperative complications (Comprehensive Complication Index (CCI®)) at discharge and 90 days after surgery, and to postoperative liver function.

RESULTS

Median intraoperative R15 (ICG retention rate at 15 min) correlated significantly with CCI® at discharge (p = 0.05) and with CCI® at 90 days (p = 0.0036). Preoperative ICG, volumetry, and scintigraphy did not correlate to postoperative outcome. ROC curve analysis revealed a cutoff value of 11.4 for the intraoperative R15 to predict major complications (Clavien-Dindo ≥ III) with 100% sensitivity and 63% specificity. No patient with R15 ≤ 11 developed major complications.

CONCLUSION

This pilot study suggests that intraoperative ICG clearance determines the functional capacity of the future liver remnant more accurately than preoperative tests. This may further reduce the number of postoperative liver failures, even if it means intraoperative abortion of hepatectomy in individual cases.

Tumor burden score-AFP-albumin-bilirubin grade score predicts the survival of patients with hepatocellular carcinoma after liver resection

PURPOSE

There is little information regarding the overall survival (OS) predictive ability of the combination of tumor burden score (TBS), α-fetoprotein (AFP), and albumin-bilirubin (ALBI) grade for patients with hepatocellular carcinoma (HCC). Here, we aimed to develop a model including TBS, AFP, and ALBI grade to predict HCC patient OS following liver resection.

METHODS

Patients (N = 1556) from six centers were randomly divided 1:1 into training and validation sets. The X-Tile software was used to determine the optimal cutoff values. The time-dependent area under the receiver operating characteristic curve (AUROC) was calculated to assess the prognostic ability of the different models.

RESULTS

In the training set, tumor differentiation, TBS, AFP, ALBI grade, and Barcelona Clinic Liver Cancer (BCLC) stage were independently related to OS. According to the coefficient values of TBS, AFP, and ALBI grade, we developed the TBS-AFP-ALBI (TAA) score using a simplified point system (0, 2 for low/high TBS, 0, 1 for low/high AFP and 0,1 for ALBI grade 1/2). Patients were further divided into low TAA (TAA ≤ 1), medium TAA (TAA = 2-3), and high TAA (TAA= 4) groups. TAA scores (low: referent; medium, HR = 1.994, 95% CI = 1.492-2.666; high, HR = 2.413, 95% CI = 1.630-3.573) were independently associated with patient survival in the validation set. The TAA scores showed higher AUROCs than BCLC stage for the prediction of 1-, 3-, and 5-year OS in both the training and validation sets.

CONCLUSION

TAA is a simple score that has better OS prediction performance than the BCLC stage in predicting OS for HCC patients after liver resection.

Liver functional assessment using time-associated change in the liver-to-spleen signal intensity ratio on enhanced magnetic resonance imaging: a retrospective study

BACKGROUND

Liver-to-spleen signal intensity ratio (LSR) is evaluated by magnetic resonance imaging (MRI) in the hepatobiliary phase and has been reported as a useful radiological assessment of regional liver function. However, LSR is a passive (non-time-associated) assessment of liver function, not a dynamic (time-associated) assessment. Moreover, LSR shows limitations such as a dose bias of contrast medium and a timing bias of imaging. Previous studies have reported the advantages of time-associated liver functional assessment as a precise assessment of liver function. For instance, the indocyanine green (ICG) disappearance rate, which is calculated from serum ICG concentrations at multiple time points, reflects a precise preoperative liver function for predicting post-hepatectomy liver failure without the dose bias of ICG or the timing bias of blood sampling. The aim of this study was to develop a novel time-associated radiological liver functional assessment and verify its correlation with traditional liver functional parameters.

METHODS

A total of 279 pancreatic cancer patients were evaluated to clarify fundamental time-associated changes to LSR in normal liver. We defined the time-associated radiological assessment of liver function, calculated using information on LSR from four time points, as the "LSR increasing rate" (LSRi). We then investigated correlations between LSRi and previous liver functional parameters. Furthermore, we evaluated how timing bias and protocol bias affect LSRi.

RESULTS

Significant correlations were observed between LSRi and previous liver functional parameters such as total bilirubin, Child-Pugh grade, and albumin-bilirubin grade (P < 0.001 each). Moreover, considerably high correlations were observed between LSRi calculated using four time points and that calculated using three time points (r > 0.973 each), indicating that the timing bias of imaging was minimal.

CONCLUSIONS

This study propose a novel time-associated radiological assessment, and revealed that the LSRi correlated significantly with traditional liver functional parameters. Changes in LSR over time may provide a superior preoperative assessment of regional liver function that is better for predicting post-hepatectomy liver failure than LSR using the hepatobiliary phase alone.

Predicting Post-Hepatectomy Liver Failure in HCC Patients: A Review of Liver Function Assessment Based on Laboratory Tests Scores

The assessment of liver function is crucial in predicting the risk of post-hepatectomy liver failure (PHLF) in patients undergoing liver resection, especially in cases of hepatocellular carcinoma (HCC) which is often associated with cirrhosis. There are currently no standardized criteria for predicting the risk of PHLF. Blood tests are often the first- and least invasive expensive method for assessing hepatic function. The Child-Pugh score (CP score) and the Model for End Stage Liver Disease (MELD) score are widely used tools for predicting PHLF, but they have some limitations. The CP score does not consider renal function, and the evaluation of ascites and encephalopathy is subjective. The MELD score can accurately predict outcomes in cirrhotic patients, but its predictive capabilities diminish in non-cirrhotic patients. The albumin-bilirubin score (ALBI) is based on serum bilirubin and albumin levels and allows the most accurate prediction of PHLF for HCC patients. However, this score does not consider liver cirrhosis or portal hypertension. To overcome this limitation, researchers suggest combining the ALBI score with platelet count, a surrogate marker of portal hypertension, into the platelet-albumin-bilirubin (PALBI) grade. Non-invasive markers of fibrosis, such as FIB-4 and APRI, are also available for predicting PHLF but they focus only on cirrhosis related aspects and are potentially incomplete in assessing the global liver function. To improve the predictive power of the PHLF of these models, it has been proposed to combine them into a new score, such as the ALBI-APRI score. In conclusion, blood test scores may be combined to achieve a better predictive value of PHLF. However, even if combined, they may not be sufficient to evaluate liver function and to predict PHLF; thus, the inclusion of dynamic and imaging tests such as liver volumetry and ICG r15 may be helpful to potentially improve the predictive capacity of these models.

Predicting Post-hepatectomy Liver Failure Preoperatively for Child-Pugh A5 Hepatocellular Carcinoma Patients by Liver Stiffness

BACKGROUND

Post-hepatectomy liver failure (PHLF) represents the major source of mortality after liver resection (LR) in hepatocellular carcinoma (HCC) patients. Child-Pugh (CP) score 5 is always considered to indicate a normal liver function but represents a heterogeneous population with a considerable number suffering from PHLF. The present study aimed to access the ability of liver stiffness (LS) measured by two-dimensional shear wave elastography (2D-SWE) to predict PHLF in HCC patients with a CP score of 5.

METHODS

From August 2018 to May 2021, 146 HCC patients with a CP score of 5 who underwent LR were reviewed. The patients were randomly divided into training (n = 97) and validation (n = 49) groups. Logistic analyses were conducted for the risk factors and a linear model was built to predict the development of PHLF. The discrimination and calibration were assessed in the training and validation cohorts by the areas under the receiver operating characteristic curve (AUC).

RESULTS

Analyses revealed that the minimum of LS (Emin) higher than 8.05 (p = 0.006, OR = 4.59) and future liver remnant / estimated total liver volume (FLR/eTLV) (p < 0.001, OR < 0.01) were independent predictors of PHLF in HCC patients with CP score 5, and the AUC calculated by the model based on them for differentiation of PHLF in the training and validation group was 0.78 and 0.76, respectively.

CONCLUSION

LS was associated with the development of PHLF. A model combining Emin and FLR/eTLV showed proper ability in predicting PHLF in HCC patients with a CP score of 5.

The preoperative M2BPGi score predicts operative difficulty and the incidence of postoperative complications in laparoscopic liver resection

BACKGROUND

Liver fibrosis or cirrhosis frequently makes parenchymal transection more difficult, but the difficulty score of laparoscopic liver resection (LLR), including the IWATE criteria, does not include a factor related to liver fibrosis. Therefore, this study aimed to evaluate M2BPGi as a predictor of the difficulty of parenchymal transection and the incidence of postoperative complications in LLR.

METHODS

Data from 54 patients who underwent laparoscopic partial liver resection (LLR-P) and 24 patients who underwent laparoscopic anatomical liver resection between 2017 and 2019 in our institution were retrospectively analyzed. All cases were classified according to M2BPGi scores, and reserve liver function, intraoperative blood loss, and postoperative complications were compared among these groups.

RESULTS

Sixteen cases (29.6%) were M2BPGi negative (cut-off index < 1.0), 25 cases (46.3%) were 1+ (1.0 ≤ cut-off index < 3.0), and 13 cases (24.1%) were 2+ (cut-off index ≥ 3.0). M2BPGi-positive cases had significantly worse hepatic reserve function (K-ICG: 0.16 vs 0.14 vs 0.08, p < 0.0001). Intraoperative bleeding was significantly greater in M2BPGi-positive cases [50 ml vs 150 ml vs 200 ml, M2BPGi (-) or (1+) vs M2BPGi (2+), p = 0.045]. Postoperative complications (Clavien-Dindo ≥ II) were significantly more frequent in M2BPGi-positive cases [0% vs 4% vs 33%, M2BPGi (-) or (1+) vs M2BPGi (2+), p = 0.001].

CONCLUSION

M2BPGi could predict surgical difficulty and complications in LLR-P. In particular, it might be better not to select M2BPGi (2+) cases as teaching cases because of the massive bleeding during parenchymal transection.

Developing and validating a nomogram based on skeletal muscle index and clinical scoring system for prediction of liver failure after hepatectomy

Background and objectives

Hepatectomy is the preferred treatment for patients with liver tumors. Post-hepatectomy liver failure (PHLF) remains one of the most fatal postoperative complications. We aim to explore the risk factors of PHLF and create a nomogram for early prediction of PHLF.

Methods

We retrospectively analyzed patients undergoing hepatectomy at the Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University between 2015 and 2022, and the patients were divided into training and internal validation cohorts at an 8:2 ratio randomly. The patients undergoing liver resection from the Affiliated Huaian Hospital of Xuzhou Medical University worked as external validation. Then, a nomogram was developed which was based on multivariate analyses to calculate the risk of PHLF. The area under the ROC curve (AUROC) and Hosmer -Lemeshow test was used to evaluate the prediction effect of the model.

Results

A total of 421 eligible patients were included in our study. Four preoperative variables were identified after multivariate analysis as follows, ASA (American Society of Anesthesiologists) score, Child-Pugh score, SMI (Skeletal muscle index), and MELD (Model for end-stage liver disease) score as independent predictors of PHLF. The area under the ROC curve of the predictive model in the training, internal, and external validation cohorts were 0.89, 0.82, and 0.89. Hosmer -Lemeshow P values in the training, internal, and external validation cohorts were 0.91, 0.22, and 0.15. The Calibration curve confirmed that our nomogram prediction results were in accurate agreement with the actual occurrence of PHLF.

Conclusion

We construct a nomogram to predict the grade B/C PHLF of ISGLS (International Study Group of Liver Surgery) in patients who underwent hepatic resection based on risk factors. This tool can provide a visual and accurate preoperative prediction of the grade B/C PHLF and guide the next step of clinical decision-making.

Thrombospondin-2 as a Predictive Biomarker for Hepatocellular Carcinoma after Hepatitis C Virus Elimination by Direct-Acting Antiviral

We evaluated the value of secreted glycoprotein thrombospondin-2 (TSP-2) to predict hepatocellular carcinoma (HCC) occurrence in chronic hepatitis C (CHC) patients after Hepatitis C virus (HCV) elimination by direct-acting antiviral agents (DAAs). A total of 786 CHC patients without an HCC history who achieved a sustained virological response (SVR) with DAAs were randomly assigned 2:1, with 524 patients as the derivation cohort and 262 patients as the validation cohort. Serum TSP-2 levels at the end of treatment were measured by enzyme-linked immunosorbent assay (ELISA). In the derivation cohort, the cumulative HCC rate was significantly higher in the high TSP-2 group than in the low TSP-2 group. Multivariate Cox proportional hazards analysis revealed that TSP-2, α-fetoprotein (AFP), and the fibrosis-4 (FIB-4) index were independent HCC risk factors. The area under the receiver operating characteristic curve (AUROC) of the score calculated from these three factors (AFT score) for predicting HCC was 0.83, which was significantly higher than that of each factor alone (TSP-2: 0.70, AFP: 0.72, FIB-4: 0.69). The AFT score was used to stratify patients according to the risk of HCC occurrence in the validation cohort. Lastly, in patients with a FIB-4 index < 3.25, the serum TSP-2 levels could be used to identify those patients with a high risk of HCC occurrence. Serum TSP-2 levels are a predictive biomarker of HCC occurrence in CHC patients after HCV elimination by DAA treatment. The AFT score using TSP-2, AFP, and the FIB-4 index may identify those who require HCC surveillance.

Fibrosis-4 index, a predictor for prognosis of hepatocellular carcinoma patients after curative hepatectomy even in hepatitis B virus dominant populations

Purpose

Liver fibrosis plays an important role in the development of hepatocellular carcinoma (HCC) and determining its prognosis. Although many staging systems and liver reserve models have been developed without the intention of predicting prognosis of HCC, some studies have investigated their prognostic values in HCC after curative liver resection (LR). The aim of this study is to evaluate prognostic value of non-invasive biomarkers after curative LR.

Methods

Between 2006 and 2013, HCC patients underwent LR were included and total 962 patients were enrolled. All non-invasive biomarkers (fibrosis 4 index (FIB-4), aspartate aminotransferase-to-platelet ratio index (APRI), aspartate aminotransferase-to-alanine aminotransferase ratio (AAR), AAR-to-platelet ratio index (AARPRI), and albumin-bilirubin (ALBI) score) were measured at the time of HCC diagnosis. To binarize each biomarker, an optimal cut-off value for fibrosis stage was selected using the value of minimum distance from the left-upper corner of the receiver operating characteristic curve with a specificity >60%. We performed Cox regression analysis on 2-year recurrence-free survival (RFS) and overall survival (OS).

Results

The area under curve values for FIB-4 and APRI were the largest for fibrosis stage compared to other biomarkers, 0.669 (95% confidential interval (CI), 0.610-0.719) and 0.748 (95% CI, 0.692-0.800), respectively. Between those two indices, FIB-4 is considered a statistically significant prognostic factor of RFS in HCC patients after LR. The HR for 2-year RFS and OS were 1.81 (95% CI, 1.18-2.77; P = 0.007) and 2.36 (95% CI, 0.99-5.65; P = 0.054), respectively.

Conclusion

FIB-4 is identified as a statistically significant predictor of HCC prognosis after curative LR even in HBV dominant populations.

Preoperative indocyanine green (ICG) clearance test: Can we really trust it to predict post hepatectomy liver failure? A systematic review of the literature and meta-analysis of diagnostic test accuracy

INTRODUCTION

Post hepatectomy liver failure (PHFL) still represents a potentially fatal complication after major liver resection. Indocyanine green (ICG) clearance test represents one of the most widely adopted examinations in the preoperative workup. Despite a copious body of evidence which has been published on this topic, the role of ICG in predicting PHLF is still a matter of debate.

METHODS

A systematic review of the literature was conducted according to PRISMA-DTA guidelines. The primary outcome was the assessment of diagnostic performance of ICG in predicting PHLF. The secondary outcome was the mean ICG_R15 and ICG_PDR in patients experiencing PHLF.

RESULTS

Seventeen studies, for a total of 4852 patients, were deemed eligible. Sensitivity ranged from 25% to 83%; Specificity ranged from 66.1% to 93.8%. ICG clearance test pooled AUC was 0.673 (95% CI: 0.632-0.713). The weighted mean ICG_R15 was 11 (95%CI: 8.3-13.7). The weighted mean ICG_PDR was 16.5 (95%CI: 13.3-19.8). High risk of bias was detected in all examined domains.

CONCLUSIONS

Preoperative ICG clearance test alone may not represent a reliable method to predict post hepatectomy liver failure. Its diagnostic significance should be framed within multiparametric models involving clinical and imaging features.

Association of preoperative albumin–bilirubin with surgical textbook outcomes following laparoscopic hepatectomy for hepatocellular carcinoma

Background and aims

Recently, the effectiveness of “textbook outcomes (TO)” in the evaluation of surgical quality has been recognized by more and more scholars. This study tended to examine the association between preoperative albumin–bilirubin (ALBI) grades and the incidence of achieving or not achieving TO (non-TO) in patients with hepatocellular carcinoma (HCC) undergoing laparoscopic hepatectomy.

Methods

The patients were stratified into two groups: ALBI grade 1 (ALBI ≤ -2.60) and ALBI grade 2/3 (ALBI > -2.60). The characteristics of patients and the incidence of non-TO were compared. Multivariate analyses were performed to determine whether ALBI grade was independently associated with TO.

Results

In total, 378 patients were enrolled, including 194 patients (51.3%) in the ALBI grade 1 group and 184 patients (48.7%) in the ALBI grade 2/3 group. In the whole cohort, 198 patients (52.4%) did not achieve TO, and the incidence of non-TO in the ALBI grade 2/3 group was obviously higher than that in the ALBI grade 1 group (n = 112, 60.9% vs. n = 86, 44.3%, P = 0.001). The multivariate analyses showed that ALBI grade 2/3 was an independent risk factor for non-TO (OR: 1.95, 95%CI: 1.30–2.94, P = 0.023).

Conclusions

More than half (52.4%) of the patients with hepatocellular carcinoma did not achieve TO after laparoscopic hepatectomy, and preoperative ALBI grade 2/3 was significantly associated with non-TO. Improving the liver function reserve of patients before operation, thereby reducing the ALBI grade, may increase the probability for patients to reach TO and enable patients to benefit more from surgery.

Machine learning models in the prediction of 1-year mortality in patients with advanced hepatocellular cancer on immunotherapy: a proof-of-concept study

INTRODUCTION

Immunotherapy is a new promising treatment for patients with advanced hepatocellular carcinoma (HCC), but is costly and potentially associated with considerable side effects. This study aimed to evaluate the role of machine learning (ML) models in predicting the 1-year cancer-related mortality in advanced HCC patients treated with immunotherapy.

METHOD

395 HCC patients who had received immunotherapy (including nivolumab, pembrolizumab or ipilimumab) between 2014 and 2019 in Hong Kong were included. The whole data sets were randomly divided into training (n = 316) and internal validation (n = 79) set. The data set, including 47 clinical variables, was used to construct six different ML models in predicting the risk of 1-year mortality. The performances of ML models were measured by the area under receiver operating characteristic curve (AUC) and their performances were compared with C-Reactive protein and Alpha Fetoprotein in ImmunoTherapY score (CRAFITY) and albumin-bilirubin (ALBI) score. The ML models were further validated with an external cohort between 2020 and 2021.

RESULTS

The 1-year cancer-related mortality was 51.1%. Of the six ML models, the random forest (RF) has the highest AUC of 0.92 (95% CI 0.87-0.98), which was better than logistic regression (0.82, p = 0.01) as well as the CRAFITY (0.68, p < 0.01) and ALBI score (0.84, p = 0.04). RF had the lowest false positive (2.0%) and false negative rate (5.2%), and performed better than CRAFITY score in the external validation cohort (0.91 vs 0.66, p < 0.01). High baseline AFP, bilirubin and alkaline phosphatase were three common risk factors identified by all ML models.

CONCLUSION

ML models could predict 1-year cancer-related mortality in HCC patients treated with immunotherapy, which may help to select patients who would benefit from this treatment.

Nomogram based on CT-derived extracellular volume for the prediction of post-hepatectomy liver failure in patients with resectable hepatocellular carcinoma

OBJECTIVES

This study aimed to develop and validate a nomogram based on extracellular volume (ECV) derived from computed tomography (CT) for predicting post-hepatectomy liver failure (PHLF) in patients with resectable hepatocellular carcinoma (HCC).

METHODS

A total of 202 patients with resectable HCC from two hospitals were enrolled and underwent multiphasic contrast-enhanced CT before surgery. One hundred twenty-one patients from our hospital and 81 patients from another hospital were assigned to the training cohort and the validation cohort, respectively. CT-derived ECV was measured using nonenhanced and equilibrium-phase-enhanced CT images. The nomogram was developed with independent predictors of PHLF. Predictive performance and calibration were assessed by receiver operator characteristic (ROC) analysis and Hosmer-Lemeshow test, respectively. The Delong test was used to compare the areas under the curve (AUCs).

RESULTS

CT-derived ECV had a strong correlation with the postoperative pathological fibrosis stage of the background liver (p < 0.001, r = 0.591). The nomogram combining CT-derived ECV, serum albumin (Alb), and serum total bilirubin (Tbil) obtained higher AUCs than the albumin-bilirubin (ALBI) score for predicting PHLF in both the training cohort (0.828 vs. 0.708; p = 0.004) and the validation cohort (0.821 vs. 0.630; p < 0.001). The nomogram showed satisfactory goodness of fit for PHLF prediction in the training and validation cohorts (p = 0.621 and 0.697, respectively).

CONCLUSIONS

The nomogram contributes to the preoperative prediction of PHLF in patients with resectable HCC.

KEY POINTS

• CT-derived ECV had a strong correlation with the postoperative pathological fibrosis stage of the background liver. • CT-derived ECV was an independent predictor of PHLF in patients with resectable HCC. • The nomogram based on CT-derived ECV showed a superior prediction efficacy than that of clinical models (including Child-Pugh stage, MELD score, and ALBI score).

A functional liver imaging score for preoperative prediction of liver failure after hepatocellular carcinoma resection

OBJECTIVES

Posthepatectomy liver failure (PHLF) is a challenging complication after resection to treat hepatocellular carcinoma (HCC), and it is associated with high mortality. Preoperative prediction of PHLF may improve patient subsequent and reduce such mortality. This study examined whether a functional liver imaging score (FLIS) based on preoperative gadoxetic acid-enhanced magnetic resonance imaging (MRI) could predict PHLF.

MATERIALS AND METHODS

The study included 502 patients who underwent preoperative gadoxetic acid-enhanced MRI, followed by HCC resection. Significant preoperative predictors of PHLF were identified using logistic regression analysis. The ability of FLIS to predict PHLF was evaluated using receiver operating characteristic curves, and its predictive power was compared to that of the model for end-stage liver disease (MELD) score, albumin-bilirubin (ALBI) score, and indocyanine green 15-min retention rate (ICG-R15).

RESULTS

In multivariate analysis, PHLF was independently associated with FLIS (OR 0.452, 95% CI 0.361 to 0.568, p < 0.001) and major resection (OR 1.898, 95% CI 1.057 to 3.408, p = 0.032). FLIS was associated with a higher area under the receiver operating characteristic curve (0.752) than the MELD score (0.557), ALBI score (0.609), or ICG-R15 (0.605) (all p < 0.05). Patients with FLIS ≤ 4 who underwent major resection were at 9.4-fold higher risk of PHLF than patients with lower FLIS who underwent minor resection.

CONCLUSION

FLIS is an independent predictor of PHLF, and it may perform better than the MELD score, ALBI score, and ICG-R15 clearance. We propose treating elevated FLIS and major resection as risk factors for PHLF.

KEY POINTS

• A functional liver imaging score can independently predict posthepatectomy liver failure in patients with HCC. • The score may predict such failure better than MELD and ALBI scores and ICG-R15. • Patients with scores ≤ 4 who undergo major hepatic resection may be at nearly tenfold higher risk of posthepatectomy liver failure.

Patient stratification in hepatocellular carcinoma: impact on choice of therapy

INTRODUCTION

HCC comprises around 60 to 80% of all primary liver cancers and exhibits wide geographical variability. Appropriate treatment allocation needs to include both patient and tumor characteristics.

AREAS COVERED

Current HCC classification systems to guide therapy are either liver function-centric and evaluate physiologic liver function to guide therapy or prognostic stratification classification systems broadly based on tumor morphologic parameters, patient performance status, and liver reserve assessment. This review focuses on different classification systems for HCC, their strengths, and weaknesses as well as the use of artificial intelligence in improving prognostication in HCC.

EXPERT OPINION

Future HCC classification systems will need to incorporate clinic-pathologic data from a multitude of sources and emerging therapies to develop patient-specific treatment plans targeting a patient's unique tumor profile.

Prediction of Posthepatectomy Liver Failure with a Combination of Albumin-Bilirubin Score and Liver Resection Percentage

BACKGROUND

Posthepatectomy liver failure (PHLF) is a main cause of death after partial hepatectomy. The aim of this study was to develop a practical stratification system using the albumin-bilirubin (ALBI) score and liver resection percentage to predict severe PHLF and conduct safe hepatectomy.

METHODS

Between January 2002 and March 2021, 361 hepatocellular carcinoma (HCC) patients who underwent partial hepatectomy were enrolled. Medical image analysis software was applied postoperatively to accurately simulate hepatectomy. The liver resection percentage was calculated as follows: (postoperatively reconstructed resected specimen volume [ml] - tumor volume [ml])/total functional liver volume (ml) × 100. Multivariate analysis was performed to identify risk factors for PHLF grade B/C. A heatmap for predicting grade B/C PHLF was generated by combining the ALBI score and liver resection percentage.

RESULTS

Thirty-nine patients developed grade B/C PHLF; 2 of these patients (5.1%) died. Multivariate analysis demonstrated that a high ALBI score and high liver resection percentage were independent predictors of severe PHLF (odds ratio [OR], 8.68, p < 0.001; OR, 1.10, p < 0.001). With a threshold PHLF probability of 50% for the heatmap, hepatectomy was performed for 346 patients meeting our criteria (95.8%) and 325 patients meeting the Makuuchi criteria (90.0%). The positive predictive value and negative predictive value for severe PHLF were 91.6% and 66.7% for our system and 91.7% and 33.3% for the Makuuchi criteria.

CONCLUSION

Our stratification system could increase the number of hepatectomy candidates and is practical for deciding the surgical indications and determining the upper limit of the liver resection percentage corresponding to each patient's liver function reserve, which could prevent PHLF and yield better postoperative outcomes.

Radiomics Analysis of Gd-EOB-DTPA Enhanced Hepatic MRI for Assessment of Functional Liver Reserve

Rationale and Objectives To evaluate the effectiveness of radiomics analysis based on Gd-EOB-DTPA enhanced hepatic MRI for functional liver reserve assessment in HCC patients. Materials and Methods Radiomics features were extracted from Gd-EOB-DTPA enhanced MRI images in 60 HCC patients. Boruta algorithm was performed to select features associated with indocyanine green retention rate at 15 min (ICG R15). Prediction and classification model were built by performing Random Forest regression analysis. Pearson correlation analysis and AUC of ROC were used to assess performance of the two models. Results A total of 165 radiomics features were extracted. Six radiomics features were selected to build the prediction model. A Predicted value of ICG R15 for each patient was calculated by the prediction model. Pearson correlation analysis revealed that predicted values were significantly associated with actual values of ICG R15 (R value = 0.90, p < 0.001). Nine radiomics features were selected to build the classification model. AUC of ROC revealed favorable performance of the classification model for identifying patients with ICG R15 <10% (AUC: 0.906, 95%CI: 0.900-0.913), <15% (AUC: 0.954, 95%CI: 0.950-0.958), and <20% (AUC: 0.996, 95%CI: 0.995-0.996). Conclusion Radiomics analysis of Gd-EOB-DTPA enhanced hepatic MRI can be used for assessment of functional liver reserve in HCC patients.

Development and Validation of a Nomogram to Preoperatively Estimate Post-hepatectomy Liver Dysfunction Risk and Long-term Survival in Patients With Hepatocellular Carcinoma

OBJECTIVE

To develop a nomogram to estimate the risk of SPLD (International Study Group of Liver Surgery definition grade B or C) and long-term survival in patients with HCC before hepatectomy.

BACKGROUND

SPLD is the leading cause of post-hepatectomy mortality. The decision to refer an HCC patient for hepatectomy is mainly based on the survival benefit and SPLD risk. Prediction of SPLD risk before hepatectomy is of great significance.

METHODS

A total of 2071 consecutive patients undergoing hepatectomy for HCC were recruited and randomly divided into the development cohort (n = 1036) and internal validation cohort (n = 1035). Five hundred ninety patients from another center were enrolled as the external validation cohort. A nomogram was developed based on independent preoperative predictors of SPLD determined in multivariable logistic regression analysis.

RESULTS

The SPLD incidences in the development, internal, and external validation cohorts were 10.1%, 9.5%, and 8.6%, respectively. Multivariable analysis identified total bilirubin, albumin, gamma-glutamyl transpeptidase, prothrombin time, clinically significant portal hypertension, and major resection as independent predictors for SPLD. Incorporating these variables, the nomogram showed good concordance statistics of 0.883, 0.851, and 0.856, respectively in predicting SPLD in the 3 cohorts. Its predictive performance in SPLD, 90-day mortality, and overall survival (OS) outperformed Child-Pugh, model for end-stage liver disease, albumin-bilirubin, and European Association for the Study of the Liver recommended algorithm. With a nomogram score of 137, patients were stratified into low and high risk of SPLD. High-risk patients also had decreased OS.

CONCLUSIONS

The nomogram showed good performance in predicting both SPLD and OS. It could help surgeons select suitable HCC patients for hepatectomy.

A novel online calculator based on noninvasive markers (ALBI and APRI) for predicting post-hepatectomy liver failure in patients with hepatocellular carcinoma

BACKGROUND AND AIM

Post-hepatectomy liver failure (PHLF) remains the primary cause of in-hospital mortality after hepatectomy. Identifying predictors of PHLF is important to improve surgical safety. We sought to identify the predictive accuracy of two noninvasive markers, albumin-bilirubin (ALBI) and aspartate aminotransferase to platelet count ratio index (APRI), to predict PHLF among patients with hepatocellular carcinoma (HCC), and to build up an online prediction calculator.

METHODS

Patients who underwent resection for HCC between 2013 and 2016 at 6 Chinese hospitals were retrospectively analyzed. The independent predictors of PHLF were identified using univariate and multivariate analyses; derivative data were used to construct preoperative and postoperative nomogram models. Receiver operating characteristic (ROC) curves for the two predictive models, and ALBI, APRI, Child-Pugh, model for end-stage liver disease (MELD) scores were compared relative to predictive accuracy for PHLF.

RESULTS

Among the 767 patients in the analytic cohort, 102 (13.3%) experienced PHLF. Multivariable logistic regression analysis identified high ALBI grade (>-2.6) and high APRI grade (>1.5) as independent risk factors associated with PHLF in both the preoperative and postoperative models. Two nomogram predictive models and corresponding web-based calculators were subsequently constructed. The areas under the ROC curves for the postoperative and preoperative models, APRI, ALBI, MELD and Child-Pugh scores in predicting PHLF were 0.844, 0.789, 0.626, 0.609, 0.569, and 0.560, respectively.

CONCLUSIONS

ALBI and APRI demonstrated more accurate ability to predict PHLF than Child-Pugh and MELD. Two online calculators that combined ALBI and APRI were proposed as useful preoperative and postoperative tools for individually predicting the occurrence of PHLF among patients with HCC.

Prognostic role of preoperative albumin-bilirubin score in posthepatectomy liver failure and mortality: a systematic review and meta-analysis

Posthepatectomy liver failure (PHLF) is a life-threatening complication after liver resection, resulting in an increased morbidity and mortality. Epidemiological evidence of the association between preoperative albumin-bilirubin (ALBI) score, a newly established model for assessing liver functional reserve, and the risk of PHLF and mortality remains controversial. A systematical search for relevant literature was performed in PubMed, Embase, and Web of Science databases from December 2014 to September 2020. Odds ratio (OR) value and 95% confidence interval (CI) were extracted or calculated to synthetically estimate the association of preoperative ALBI score with PHLF and mortality. Meta-analyses were performed using a random-effects model. Twelve studies with a total of 21,348 patients were included in this meta-analysis. It was indicated that, compared to patients with a lower preoperative ALBI grade, patients with a higher grade had a significantly elevated risk of PHLF (6 studies, 18,291 patients; OR = 2.48, 95%CI: 2.00-3.07) and mortality (4 studies15, 139 patients; OR = 2.35, 95% CI: 1.38-4.00). In addition, when it was expressed as a continuous variable, ALBI was also a significant predictor of PHLF (6 studies, 3,833 patients; OR = 3.16, 95% CI: 2.07-4.81, per 1-point increase in ALBI score). No significant publication biases were detected as suggested by funnel plots inspection and Begg's tests. The current meta-analysis demonstrates that preoperative elevated ALBI is associated with higher risk of PHLF and mortality after hepatectomy.

Prognostic Value of the Albumin-Bilirubin Grade for the Prediction of Post-Hepatectomy Liver Failure: A Systematic Review and Meta-Analysis

(1) Introduction: Liver resection (LR) for hepatocellular carcinoma (HCC) is often burdened by life-threatening complications, such as post-hepatectomy liver failure (PHLF). The albumin-bilirubin (ALBI) score can accurately evaluate liver function and the long-term prognosis of HCC patients, including PHLF. We aimed to evaluate the diagnostic value of the ALBI grade in predicting PHLF in HCC patients undergoing LR. (2) Methods: MEDLINE, Embase, and Scopus were searched through January 17th, 2021. Studies reporting the ALBI grade and PHLF occurrence in HCC patients undergoing LR were included. The Odds Ratio (OR) prevalence with 95% confidence intervals (CI) was pooled, and the heterogeneity was expressed as I2. The quality of the studies was assessed using QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies). (3) Results: Seven studies met the inclusion criteria and were included in the analysis. A total of 5377 patients who underwent LR for HCC were considered, of whom 718 (13.4%) developed PHLF. Patients with ALBI grades 2 and 3 before LR showed increased rates of PHLF compared to ALBI grade 1 patients. The pooled OR was 2.572 (95% CI, 1.825 to 3.626, p < 0.001), with substantial heterogeneity between the studies (I2 = 69.6%) and no publication bias (Begg's p = 0.764 and Egger's p = 0.851 tests). All studies were at a 'low risk' or 'unclear risk' of bias. Univariate meta-regression analysis showed that heterogeneity was not dependent on the country of study, the age and sex of the participants, the definition of PHLF used, the rate of patients in Child-Pugh class A or undergoing major hepatectomy. (4) Conclusions: In this meta-analysis of published studies, individuals with ALBI grades of 2 and 3 showed increased rates of PHLF compared to ALBI grade 1 patients.

Association between preoperative prealbumin level and postoperative mortality and morbidity after hepatic resection for hepatocellular carcinoma: A multicenter study from a HBV-endemic area

BACKGROUND

Prealbumin is a more sensitive serum biomarker in reflecting liver function and nutritional status than albumin, because of its shorter half-life and its characteristics that could hardly be affected by supplemental venous infusion of albumin or blood transfusion. This study aimed to identify whether preoperative prealbumin level was associated with postoperative mortality and morbidity after hepatic resection for patients with hepatocellular carcinoma (HCC).

METHODS

From a Chinese multicenter database, patients who underwent hepatic resection for HCC were divided into the low and normal prealbumin groups by using 17 mg/dL as the cut-off level for serum prealbumin taken within a week before surgery. Using univariable and multivariable logistic regression analyses, independent predictors associated with postoperative 30-day and 90-day mortality, 30-day overall and major morbidity, and postoperative hepatic insufficiency were identified.

RESULTS

Among 1356 patients, 409 (30.2%) had a low preoperative prealbumin level. Postoperative 30-day and 90-day mortality, and 30-day overall and major morbidity in the low prealbumin group were significantly higher than the normal prealbumin group (2.9% vs. 0.5%, 5.1% vs. 1.5%, 35.7% vs. 18.4%, and 14.4% vs. 6.5%, respectively, all P < 0.001). Multivariable analyses identified that preoperative prealbumin level, but not albumin level, was independently associated with postoperative 30-day mortality (OR: 3.486, 95% CI: 1.184-10.265), 90-day mortality (2.504, 1.219-5.145), 30-day overall morbidity (1.727, 1.302-2.292), 30-day major morbidity (1.770, 1.155-2.711) and postoperative hepatic insufficiency (1.967, 1.119-3.427).

CONCLUSIONS

Preoperative prealbumin level could be used to predict postoperative morbidity and mortality for patients treated with hepatic resection for HCC.

Comparison between preoperative two-dimensional shear wave elastography and indocyanine green clearance test for prediction of post-hepatectomy liver failure

BACKGROUND

Post-hepatectomy liver failure (PHLF) is one of the most serious complications and major causes of liver resection mortality. The purpose of this study is to investigate and compare the performance of preoperative two-dimensional shear wave elastography (2D-SWE) and the indocyanine green (ICG) clearance test for the prediction of PHLF.

METHODS

A total of 172 consecutive patients who were undergoing major liver resection were prospectively identified. Patients were evaluated by preoperative 2D-SWE and ICG clearance test. According to the International Study Group of Liver Surgery (ISGLS) recommendations, No PHLF, PHLF A, PHLF B, and PHLF C group classifications were defined. The differences in liver stiffness value (LSV) and ICG retention rate at 15 minutes (ICGR15) among the different PHLF classifications were investigated. The performance of LSV and ICGR15 for diagnosing different classifications of PHLF was compared.

RESULTS

PHLF occurred in 43 (25.0%) patients, and 24 (14.0%) patients were grade A, 14 (8.1%) were grade B, and 5 (2.9%) were grade C. Both LSV and ICGR15 of the PHLF C group were significantly higher than those of the No PHLF group (P=0.025, P=0.001, respectively). According to univariate and multivariate logistic regression analysis, LSV and ICGR15 were significantly related to PHLF (P=0.051, P=0.084, respectively). For diagnosis of ≥ PHLF A, ≥ PHLF B, and ≥ PHLF C, the areas under the receiver operating characteristic curve (AUCs) for 2D-SWE were 0.624 [95% confidence interval (CI): 0.536-0.712, P=0.015], 0.699 (95% CI: 0.576-0.821, P=0.005), and 0.831 (95% CI: 0.737-0.925, P=0.01), respectively. The AUCs of the ICG clearance test were 0.631 (95% CI: 0.542-0.721, P=0.01), 0.570 (95% CI: 0.436-0.704, P=0.32), and 0.717 (95% CI: 0.515-0.920, P=0.098), respectively. The AUC of LSV for the diagnosis of ≥ PHLF A was comparable to that of ICGR15 (P=0.17). The AUCs of LSV were significantly higher than those of ICGR15 for the diagnosis of ≥ PHLF B (P=0.002) and C (P=0.038).

CONCLUSIONS

2D-SWE demonstrates the potential to aid in the prediction of the severity of PHLF. Our findings also suggest that the performance of 2D-SWE is better than the ICG clearance test.

The Assessment of Regional Liver Function Before Major Hepatectomy Using Magnetic Resonance Imaging

BACKGROUND

The liver-to-spleen signal intensity ratio (LSR) on magnetic resonance imaging with gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid has been used as a parameter to assess liver function. LSR of the future remnant liver region (FR-LSR) is included in preoperative assessment of regional liver function. The aim of this study was to investigate the predictability of post-hepatectomy liver failure (PHLF) by FR-LSR.

METHODS

Between May 2013 and May 2019, 127 patients underwent standardized EOB-MRI for diagnosis of liver tumor before major hepatectomy. The FR-LSR on EOB-MRI was calculated by a semiautomated three-dimensional volumetric analysis system. The cutoff value of FR-LSR in association with clinically relevant PHLF was determined according to the areas under the receiver operating characteristic curves. Then, FR-LSR and clinical variables were analyzed to assess the risk of clinically relevant PHLF.

RESULTS

In patients with preoperative biliary drainage, metastatic liver tumor, estimated future remnant liver volume <50%, biliary reconstruction, operation time ≥ 480 min, estimated blood loss ≥ 1000 g, blood transfusion and a FR-LSR < 2.00 were associated with clinically relevant PHLF (P < .05 for all) in univariable analysis. The liver-to-spleen signal intensity ratio of the future remnant liver region < 2.00 was the only independent risk factor for clinically relevant PHLF in multivariable risk analysis (OR, 27.90; 95% CI: 7.99-136.40; P < .05).

DISCUSSION

The present study revealed that FR-LSR calculated using a 3-dimensional volumetric analysis system was an independent risk factor for clinically relevant PHLF. The liver-to-spleen signal intensity ratio of the future remnant liver region might be a reliable preoperative parameter in liver functional assessment, enabling safe performance of major hepatectomy.

Development and Validation of a Nomogram Based on Noninvasive Liver Reserve and Fibrosis (PALBI and FIB-4) Model to Predict Posthepatectomy Liver Failure Grade B-C in Patients with Hepatocellular Carcinoma

Hepatectomy is currently one of the most effective treatments for hepatocellular carcinoma (HCC). However, postoperative liver failure (PHLF) is a serious complication and the leading cause of mortality in patients with HCC after hepatectomy. This study attempted to develop a novel nomogram based on noninvasive liver reserve and fibrosis models, platelet-albumin-bilirubin grade (PALBI) and fibrosis-4 index (FIB-4), able to predict PHLF grade B-C. This was a single-centre retrospective study of 574 patients with HCC undergoing hepatectomy between 2014 and 2018. The independent risk factors of PHLF were screened using univariate and multivariate logistic regression analyses. Multivariate logistic regression was performed using the training set, and the nomogram was developed and visualised. The utility of the model was evaluated in a validation set using the receiver operating characteristic (ROC) curve. A total of 574 HCC patients were included (383 in the training set and 191 for the validation set) and included PHLF grade B-C complications of 14.8, 15.4, and 13.6%, respectively. Overall, cirrhosis (P < 0.026, OR = 2.296, 95% confidence interval (CI) 1.1.02-4.786), major hepatectomy (P=0.031, OR = 2.211, 95% CI 1.077-4.542), ascites (P=0.014, OR = 3.588, 95% 1.299-9.913), intraoperative blood loss (P < 0.001, OR = 4.683, 95% CI 2.281-9.616), PALBI score >-2.53 (, OR = 3.609, 95% CI 1.486-8.764), and FIB-4 score ≥1.45 (P < 0.001, OR = 5.267, 95% CI 2.077-13.351) were identified as independent risk factors associated with PHLF grade B-C in the training set. The areas under the ROC curves for the nomogram model in predicting PHLF grade B-C were significant for both the training and validation sets (0.832 vs 0.803). The proposed nomogram predicted PHLF grade B-C among patients with HCC with a better prognostic accuracy than other currently available fibrosis and noninvasive liver reserve models.

Comparison of preoperative two-dimensional shear wave elastography, indocyanine green clearance test and biomarkers for post hepatectomy liver failure prediction in patients with hepatocellular carcinoma

BACKGROUND

The preoperative prediction of post hepatectomy liver failure (PHLF) is essential, but there is no gold standard for the prediction at present, and the efficacy of different methods for the prediction has not been compared systematically. In this study, we aimed to compare the efficacy of preoperative two-dimensional shear wave elastography (2D-SWE), indocyanine green (ICG) clearance test and biomarkers for PHLF prediction in patients with hepatocellular carcinoma (HCC).

METHODS

We retrospectively studied 215 patients with HCC, who had undergone major liver resection in our hospital. Preoperative data of each patient, including liver stiffness value (LSV) of underlying hepatic parenchyma measured by 2D-SWE, ICG retention rate at 15 min (ICG-R15) measured by ICG clearance test, albumin-bilirubin (ALBI) scores, aspartate aminotransferase-platelet ratio index (APRI), and Fibrosis-4 (FIB-4) were collected for analysis. Post hepatectomy outcomes of study patients were also recorded for assessment of PHLF. The study patients were divided into development cohort (133 patients without PHLF, and 17 patients with PHLF) and validation cohort (59 patients without PHLF, and 6 patients with PHLF) randomly.

RESULTS

In the development cohort, LSV, ICG-R15 and ALBI scores were significantly different between patients with and without PHLF, while no significant difference of APRI and FIB-4 scores was found. LSV had higher AUC (the area under the receiver operating characteristic curve) (AUC = 0.795) for PHLF prediction than ICG-R15 (AUC = 0.619) and ALBI scores (AUC = 0.686) (p < 0.05 for all comparisons). In the validation cohort, the cutoff value of LSV obtained from the development cohort, 10.35 kPa,  revealed higher specificity (76.3%) for PHLF prediction than ICG-R15 (specificity: 66.1%) and ALBI scores (specificity: 69.5%) (p < 0.0001).

CONCLUSIONS

Compared with ICG-R15, ALBI scores, APRI and FIB-4, LSV measured by 2D-SWE may demonstrate better efficacy for preoperative PHLF prediction in patients with HCC.

Effectiveness of Albumin-bilirubin Score as a Predictor of Post-hepatectomy Liver Failure in Patients with Hepatocellular Carcinoma

Backgrounds/Aims

Post-hepatectomy liver failure (PHLF) is a major concern for patients with hepatocellular carcinoma (HCC) who have undergone liver resection. The albumin-bilirubin (ALBI) score is a novel model for assessing liver function. We aimed to investigate the effectiveness of the ALBI score as a predictor of PHLF in HCC patients who have undergone hepatectomy in South Korea.

Methods

Between January 2014 and November 2018, HCC patients who underwent hepatectomy and indocyanine retention rate at 15 min (ICG-R15) test were enrolled in this study.

Results

A total of 101 patients diagnosed with HCC underwent hepatectomy. Thirty-two patients (31.7%) experienced PHLF. The ALBI score (OR 2.83; 95% CI 1.22-6.55; p=0.015), ICG-R15 (OR 1.07; 95% CI 1.02-1.12; p=0.007) and ALBI grade (OR 2,86; 95% CI 1.08-7.58; p=0.035) were identified as independent predictors of PHLF by multivariable analysis. The area under the receiver operating characteristic curve of the ALBI score and ICG-R15 were 0.676 (95% CI 0.566-0.785) and 0.632 (95% CI 0.513-0.752), respectively. The optimal cutoff value of the ALBI score in predicting PHLF was -2.62, with a sensitivity of 75.0% and a specificity of 56.5%.

Conclusions

The ALBI score is an effective predictor of PHLF in patients with HCC, and its predictive ability is comparable to that of ICG-R15.

[Liver Resections Can Be Safely Performed in Cirrhotic Patients after Careful Patient Selection]

BACKGROUND

Hepatocellular Carcinoma (HCC) is the most frequent malignant primary liver tumour in a cirrhotic liver. Liver transplantation and resection are the only curative treatment options in compensated liver cirrhosis, but liver resections are associated with increased perioperative morbidity and mortality.

PATIENTS

We identified 108 cirrhotic patients, who underwent liver resections at the University Hospital of Mainz between January 2008 and December 2019. During the same period, 185 liver resections were performed for HCC in non-cirrhotic livers. Furthermore, 167 liver resections served as control group, which were performed for colorectal liver metastases (CRLM) with comparable extent of resection to HCC in cirrhotic livers. Preoperatively, we assessed the Charlson Comorbidity Index (CCI), MELD and Child scores in addition to the general patient characteristics. Perioperative morbidity was graded according to the Clavien-Dindo classification. Resections of HCC in cirrhosis and liver metastases were additionally compared by a matched-pair analysis.

RESULTS

The three groups were comparable in age. Preoperative liver function was best in patients with CRLM (p < 0.001). Resections for HCC in non-cirrhotic livers were more extended than in cirrhotic livers (p < 0.001). The overall morbidity (Clavien/Dindo stage III - IV) was higher after resections in cirrhotic livers than in CRLM resections (p = 0.026). Postoperative mortality was comparably low in all three groups (2.2%). Neither MELD nor Child score was predictive for postoperative morbidity or mortality (area under the curve: AUC < 0.6, each). Preoperative CCI was predictive for postoperative mortality (AUC = 0.78).

CONCLUSIONS

Liver resections in cirrhotic livers are feasible after adequate patient selection and limitation of the extent of surgery. Comorbidities additionally increase the postoperative mortality in addition to impaired liver function and should therefore always be included into the preoperative assessment of patients undergoing liver surgery.

Combination of albumin-bilirubin grade and clinically significant portal hypertension predicts the prognosis of patients with hepatocellular carcinoma after liver resection

There is little information concerning whether incorporating clinically significant portal hypertension (CSPH) into albumin-bilirubin (ALBI) grading could improve its predictive capacity. In this study, we investigated the predictive ability of ALBI grade plus CSPH (ALBI-P score) for patients with hepatocellular carcinoma (HCC) after liver resection. Data from 1,679 patients were retrospectively reviewed. The ALBI-P score was calculated from the ALBI grade and a point for CSPH (0 for absence of CSPH and 1 for presence of CSPH). Independent risk factors for recurrence-free survival (RFS) and overall survival (OS) were analyzed. Multivariate analysis suggested that the ALBI-P score was an independent risk factor for both postoperative recurrence (HR = 1.441, 95% CI = 1.328-1.563, P < 0.001) and mortality (HR = 1.332, 95% CI = 1.156-1.535, P < 0.001). Both the RFS and OS of patients with an ALBI-P score of 1 were significantly better than those of patients with ALBI-P scores of 2 and 3 (5-year RFS of 38.9%, 26.1%, and 14.7%, respectively, P < 0.001; 5-year OS of 52.7%, 42.6%, and 29.3%, P < 0.001). When the ALBI-P score and BCLC stage were combined, the ALBI-P-BCLC score showed the highest area under the receiver operating characteristic curve to predict both postoperative recurrence and mortality compared with BCLC stage alone, BCLC stage combined with ALBI grade, or platelet-albumin-bilirubin grade. These results suggested incorporating CSPH into the ALBI grade could strengthen its prognostic power. The ALBI-P score may serve as a surrogate marker to predict HCC patient outcomes after liver resection.

HCC surveillance after SVR in patients with F3/F4 fibrosis

HCV eradication by antiviral treatment reduces but does not eliminate HCC risk. Patients with established cirrhosis require HCC surveillance "indefinitely" after sustained virologic response (SVR) because they appear to have a high risk of HCC even many years after SVR. Patients without established or known cirrhosis may still require surveillance after SVR if they have a sufficiently high HCC risk. In all patients who achieve SVR, the key question is how we can reliably estimate HCC risk, and the change in HCC risk over time, to determine whether the patient might benefit from HCC surveillance. HCC risk is one of the most important factors that should inform decisions of whether and how to screen for HCC. Promising strategies for estimating HCC risk include simplified scoring systems (such as fibrosis-4), liver elastography and multivariable HCC risk calculators. Such tools may enable risk stratification and individualised, risk-based surveillance strategies ("precision HCC screening") in the future.

The Significance of Platelet-Albumin-Bilirubin (PALBI) Grade in Hepatocellular Carcinoma Patients Stratified According to Platelet Count

Background

Platelet–albumin–bilirubin (PALBI) has been demonstrated to be superior to conventional Child–Pugh (C-P) grade in evaluating liver function and prognosis of HCC patients. However, both thrombocytosis and thrombocytopenia are unfavorable for HCC survival. The aim of this study was to preliminarily investigate the prognostic value of PALBI in HCC patients with thrombocytopenia and excluding thrombocytopenia.

Methods

In this retrospective cohort study, we reviewed 465 cases of HCC patients who underwent radical surgery. PALBI grade was calculated based on preoperative serological examinations. The primary outcomes were overall survival (OS) and recurrence-free survival (RFS), which were assessed by Kaplan–Meier method and Cox regression. The prognostic performances of PALBI and other models were estimated by using the concordance index (C-index).

Results

During a median follow-up time of 28 months, 31.6% (147/465) of patients died and 33.5% (156/465) experienced recurrence. Multivariate analyses revealed that both thrombocytosis and thrombocytopenia were independently associated with poor OS and RFS compared with normal platelet count (PLT) in HCC patients. Stratified analysis further revealed that PALBI was a significant predictor for HCC survival in patients excluding thrombocytopenia but not in patients with thrombocytopenia. In particular, in HCC patients excluding thrombocytopenia, the combination of tumor size with PALBI (C-index = 0.730, 95% CI: 0.674–0.786) may be superior to the classical Barcelona Clinic Liver Cancer (BCLC) and Cancer of Liver Italian Program (CLIP) staging systems in predicting survival.

Conclusion

In conclusion, PALBI grade, in particular the combination with tumor size, is an effective model for discriminating survival in HCC patients excluding thrombocytopenia but not in thrombocytopenic HCC patients.

A novel online calculator based on albumin-bilirubin and aspartate transaminase-to-platelet ratio index for predicting postoperative morbidity following hepatectomy for hepatocellular carcinoma

Email

zhangchengwuzr@hotmail.com; Prof. Tian Yang, MD. Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Navy Medical University, Shanghai 200438, China. Email: yangtiandfgd@hotmail.com.

Background

Identifying patients at high risks of developing postoperative morbidity is important to improve perioperative outcomes. We sought to define the accuracy of two objective and non-invasive serological-based scores, i.e., albumin-bilirubin (ALBI) and aspartate transaminase-to-platelet ratio index (APRI), to predict postoperative morbidity among patients undergoing hepatectomy for hepatocellular carcinoma (HCC), and build up a personalized predictive tool for clinical practice.

Methods

Clinical data of patients who underwent hepatectomy for HCC at 8 hospitals from a multicenter database were retrospectively analyzed. The predictive accuracy of ALBI and APRI relative to 30-day overall and major morbidity were evaluated using area under the receiver operating characteristic curves (AUC). Based on multivariable logistic regression analyses, preoperative and postoperative nomogram models and consequent online calculators were constructed to predict overall and major morbidity, respectively.

Results

Among 2,301 patients, 725 (31.5%) experienced postoperative complications (major morbidity, 35.9%, 260/725). Multivariable analyses identified high ALBI grade (>−2.6) and APRI grade (>1.5) as independent risk factors associated with overall and major morbidity in both preoperative and postoperative prediction models. Two nomogram predictive models and corresponding online calculators that combined ALBI and APRI were subsequently constructed. The AUCs of the preoperative and postoperative models were 0.728 and 0.742 to predict overall morbidity, and 0.739 and 0.713 to predict major morbidity, respectively, which were much higher than those of Child-Pugh score and the model for end-stage liver disease (MELD). Using the bootstrap validation method, the resulting models were internally validated well.

Conclusions

Preoperative ALBI and APRI scores can predict postoperative morbidity following hepatectomy for HCC. An easy-to-use online calculator that combined ALBI and APRI was proposed for individually predicting the probabilities of postoperative overall and major morbidity before and immediately after surgery, so as to provide useful information to inform conversations about surgical risks.

Preoperative Albumin-Bilirubin Grade With Prognostic Nutritional Index Predicts the Outcome of Patients With Early-Stage Hepatocellular Carcinoma After Percutaneous Radiofrequency Ablation

Background: Prognostic nutritional index (PNI) that was designed to assess the nutritional and immunological status of patients and albumin–bilirubin (ALBI) grades can be used as an assessment tool for hepatic function. Both nutritional and immunological statuses have been reported to be independent prognostic factors of patients with hepatocellular carcinoma (HCC). This study aimed to investigate whether PNI together with ALBI could be a better predictor in patients with early-stage HCC undergoing radiofrequency ablation (RFA).

Method: The information of 110 patients with newly diagnosed HCC within the Milan criteria receiving RFA as the initial therapy between 2014 and 2015 was retrospectively collected. Pretreatment PNI, ALBI, and PNI-ALBI grades were calculated. Overall survival (OS) and recurrence-free survival (RFS) were estimated by the Kaplan–Meier method, and multivariate analysis was used to identify prognostic factors.

Result: The 1-, 3-, and 5-years OS rates of patients were 80.0, 30.9, and 23.9%, respectively. Multivariate analysis showed that the tumor size [hazard ratio (HR) = 1.966, 95% confidence interval (CI) = 1.091–3.545, P = 0.025], PNI grade (H = 2.558, 95% CI = 1.289–5.078, P = 0.007), and PNI-ALBI grade (HR = 3.876, 95% CI = 1.729–8.690, P = 0.001) were independent risk factors for OS, whereas only the elevated α-fetoprotein (HR = 1.732, 95% CI = 1.003–2.991, P = 0.049) and the size of the tumor (HR = 1.640, 95% CI = 1.015–2.647, P = 0.43) were independent predictors for better RFS.

Conclusion: This study demonstrates that preoperative PNI-ALBI grade is a simple and useful predictor for OS in patients with early-stage HCC after RFA.

Nomogram for prediction of the international study Group of Liver Surgery (ISGLS) grade B/C Posthepatectomy liver failure in HBV-related hepatocellular carcinoma patients: an external validation and prospective application study

BACKGROUND

To develop a nomogram for predicting the International Study Group of Liver Surgery (ISGLS) grade B/C posthepatectomy liver failure (PHLF) in hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) patients.

METHODS

Patients initially treated with hepatectomy were included. Univariate regression analysis and stochastic forest algorithm were applied to extract the core indicators and reduce redundancy bias. The nomogram was then constructed by using multivariate logistic regression, and validated in internal and external cohorts, and a prospective clinical application.

RESULTS

There were 900, 300 and 387 participants in training, internal and external validation cohorts, with the morbidity of grade B/C PHLF were 13.5, 11.0 and 20.2%, respectively. The nomogram was generated by integrating preoperative total bilirubin, platelet count, prealbumin, aspartate aminotransferase, prothrombin time and standard future liver remnant volume, then achieved good prediction performance in training (AUC = 0.868, 95%CI = 0.836-0.900), internal validation (AUC = 0.868, 95%CI = 0.811-0.926) and external validation cohorts (AUC = 0.820, 95%CI = 0.756-0.861), with well-fitted calibration curves. Negative predictive values were significantly higher than positive predictive values in training cohort (97.6% vs. 33.0%), internal validation cohort (97.4% vs. 25.9%) and external validation cohort (94.3% vs. 41.1%), respectively. Patients who had a nomogram score < 169 or ≧169 were considered to have low or high risk of grade B/C PHLF. Prospective application of the nomogram accurately predicted grade B/C PHLF in clinical practise.

CONCLUSIONS

The nomogram has a good performance in predicting ISGLS grade B/C PHLF in HBV-related HCC patients and determining appropriate candidates for hepatectomy.

Clinical Role of Newly Developed ALBI and mALBI Grades for Treatment of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is a leading cause of death worldwide. The selection of therapeutic modalities and the prognosis of affected patients are well known to be dependent not only on the tumor burden but also on the hepatic reserve function. Antiviral treatments for chronic hepatitis related to a viral infection and an increase in cases of nonviral HCC associated with the aging of society have resulted in dramatic changes regarding the characteristics of HCC patients. With recent developments in therapeutic modalities for HCC, a more detailed assessment of hepatic function has become an important need. Studies in which the relationship of albumin-bilirubin (ALBI) grade with the prognosis of HCC patients was investigated were reviewed in order to evaluate the usefulness of newly developed ALBI and modified ALBI (mALBI) grades for HCC treatment, as those scoring methods are considered helpful for predicting the prognosis and selecting therapeutic modalities based on the expected prognosis.

Assessment of the Outcomes of Intrahepatic Cholangiocarcinoma After Ultrasound-Guided Percutaneous Microwave Ablation Based on Albumin-Bilirubin Grade

OBJECTIVE

To determine whether albumin-bilirubin (ALBI) grade could be used to predict the outcomes of patients with intrahepatic cholangiocarcinoma (ICC) who underwent ultrasound-guided percutaneous microwave ablation (MWA).

MATERIALS AND METHODS

This retrospective study was approved by the institutional review board, and the requirement for informed consent was waived. We studied 52 treatment-naïve patients with 74 ICC lesions according to the Milan criteria who subsequently underwent MWA from April 2011 to March 2018. Overall survival (OS) and recurrence-free survival (RFS) were compared in groups classified by Child-Pugh score and ALBI grade, which were statistically analyzed with the log-rank test. Cox proportional hazard regression analyses were used to determine the prognostic factors for survival in patients with ICC.

RESULTS

The median follow-up time was 21.2 months (3.2-78.7 months). Seventeen patients died during this period. After MWA, the cumulative 1-, 3-, and 5-year OS rates were 87.4%, 51.4%, and 35.2%, respectively, and the cumulative 1-, 3-, and 5-year RFS rates were 68.9%, 56.9%, and 56.9%, respectively. The major complication rate was 3.8% (2/52). Stratified according to ALBI grade, the cumulative 1-, 3-, and 5-year OS rates were 95.5%, 72.4%, and 72.4% for patients with ALBI grade 1 and 62.5%, 40.6%, and 36.3% for patients with ALBI grade 2, respectively, showing a significant difference (P = 0.006). Multivariate analysis results showed that older age (hazard ratio [HR]: 1.67, 95% confidence interval [CI]: 1.11-2.82; P = 0.002), tumor size ≥ 3 cm in diameter (HR: 11.33, CI: 2.24-34.52; P = 0.021) and ALBI grade (HR: 8.23, CI: 1.58-58.00; P = 0.004) may be predictors of poor OS.

CONCLUSION

ALBI grade was validated as a significant biomarker for predicting survival in ICC patients within the Milan criteria who underwent MWA.

An Improved Scoring System Based on Platelet-Albumin-Bilirubin in Predicting Posthepatectomy Liver Failure Outcomes

BACKGROUND

Posthepatectomy liver failure (PHLF) is one of the major complications of liver resection that causes perioperative mortality. Accurate preoperative assessment of PHLF is of great significance to reduce the complication rate after hepatectomy and improve the survival rate.

METHODS

A retrospective study of patients who received hepatectomy from January 2016 to October 2019 at Tang Du Hospital was performed. The area under the receiver operating characteristic (ROC) curve was used to compare the predictive effects of various scoring models on PHLF.

RESULTS

The area under the ROC curve of platelet-albumin-bilirubin (PALBI) score, new platelet-albumin-bilirubin (I-PALBI) score, ALBI score, and MELD score was, respectively, 0.647, 0.772, 0.677, and 0.686 (p < 0.01). The I-PALBI score was significantly better than the other scores.

CONCLUSIONS

I-PALBI score can be used as a predictive score of PHLF, and its prediction accuracy is better than other scoring systems.