Development and Validation of Pre- and Post-Operative Models to Predict Recurrence After Resection of Solitary Hepatocellular Carcinoma: A Multi-Institutional Study

The ALBI score: From liver function in patients with HCC to a general measure of liver function

The (albumin-bilirubin) ‘ALBI’ score is an index of ‘liver function’ that was recently developed to assess prognosis in patients with hepatocellular carcinoma, irrespective of the degree of underlying liver fibrosis. Other measures of liver function, such as model for end-stage liver disease (MELD) and Child-Pugh score, which were introduced for specific clinical scenarios, have seen their use extended to other areas of hepatology. In the case of ALBI, its application has been increasingly extended to chronic liver disease in general and in some instances to non-liver diseases where it has proven remarkably accurate in terms of prognosis. With respect to chronic liver disease, numerous publications have shown that ALBI is highly prognostic in patients with all types and stages of chronic liver disease. Outside of liver disease, ALBI has been reported as being of prognostic value in conditions ranging from chronic heart failure to brain tumours. Whilst in several of these reports, explanations for the relationship of liver function to a clinical condition have been proposed, it has to be acknowledged that the specificity of ALBI for liver function has not been clearly demonstrated. Nonetheless, and similar to the MELD and Child-Pugh scores, the lack of any mechanistic basis for ALBI’s clinical utility does not preclude it from being clinically useful in certain situations. Why albumin and bilirubin levels, or a combination thereof, are prognostic in so many different diseases should be studied in the future.

ALBI grade: Evidence for an improved model for liver functional estimation in patients with hepatocellular carcinoma

Hepatocellular carcinoma (HCC) usually arises in the context of a chronically damaged liver. Liver functional estimation is of paramount importance in clinical decision making. The Child-Pugh score (CPS) can be used to categorise patients into 3 classes (A to C) based on the severity of liver functional impairment according to 5 parameters (albumin, bilirubin, prothrombin time, presence of ascites and hepatic encephalopathy). The albumin-bilirubin (ALBI) grade has emerged as an alternative, reproducible and objective measure of liver functional reserve in patients with HCC, defining worsening liver impairment across 3 grades (I to III). The ALBI score can identify different subgroups of patients with different prognoses across the diverse Barcelona Clinic Liver Cancer stages and CP classes, making it an appealing clinical predictor. In patients treated with potentially curative approaches (resection, transplantation, radiofrequency ablation, microwave ablation), ALBI grade has been shown to correlate with survival, tumour relapse, and post-hepatectomy liver failure. ALBI grade also predicts survival, toxicity and post-procedural liver failure in patients treated with transarterial chemoembolisation, radioembolisation, external beam radiotherapy as well as multi-kinase inhibitors (sorafenib, lenvatinib, cabozantinib, regorafenib) and immune checkpoint inhibitor therapy. In this review, we summarise the body of evidence surrounding the role of ALBI grade as a biomarker capable of optimising patient selection and therapeutic sequencing in HCC.

Single Large Nodule (>5 cm) Prognosis in Hepatocellular Carcinoma: Kinship with Barcelona Clinic Liver Cancer (BCLC) Stage A or B?

Background

The aim of the present study was to evaluate the prognosis among patients with a single large hepatocellular carcinoma (HCC) >5 cm compared with other patients in Barcelona Clinic Liver Cancer (BCLC) stage A or stage B.

Material/Methods

Data on patients with BCLC stage A/B HCC were collected between 2008 and 2012. BCLC stage A was subclassified as A1 (single tumor, 2–5 cm, or 2–3 nodules ≤3 cm), or A2 (single tumor >5 cm). Overall survival (OS) was evaluated and compared.

Results

Among 1005 patients with HCC, 455 were stage A1, 188 were stage A2, and 362 were stage B. The OS of stage A2 patients was significantly worse than that of stage A1 patients (median survival, 30.6 vs. 43.2 months, p<0.001), and was similar to that of stage B patients (median survival, 30.6 vs. 33.5 months, p=0.519). After surgical resection, OS was statistically distinct between stage A1+A2 and B (median survival, 51.2 vs. 36.0 months, p=0.001), and between stage A1 and A2+B (median survival, 54.4 vs. 36.8 months, p<0.001). In contrast, when treated by transarterial chemoembolization, there was no difference in OS between patients with stage A1+A2 HCC and patients with stage B HCC (median survival, 32.4 vs. 31.3 months, p=0.310), whereas patients with stage A1 HCC showed a significantly more favorable OS than those with stage A2+B HCC (median survival, 39.6 vs. 31.8 months, p=0.023). On multivariable analysis, the groupings that showed significantly different associations with OS were BCLC stage A2+B vs. A1 (hazard ratio 1.6, p<0.001) rather than stage B vs. A1+A2.

Conclusions

Patients with solitary HCC >5 cm had a comparable survival with BCLC stage B. HCC >5 cm should therefore be classified as an intermediate stage.