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PLATELET-ALBUMIN GRADE (PAL GRADE) AS A SENSITIVE MEASURE FOR SURGICAL RISK PREDICTION AND SURVIVAL OUTCOMES OF PATIENTS WITH HEPATOCELLULAR CARCINOMA
Junichi Shindoh^*, Yuta Kobayashi, Masaji Hashimoto
Hepatobiliary Surgery Division, Toranomon Hospital, Tokyo, Japan

Introduction: Most patients with hepatocellular carcinoma (HCC) have underlying chronic liver disease, the severity of which has recently been assessed by new grading systems including ALBI grade (albumin + bilirubin) or ALICE grade (albumin + indocyanine green clearance) in addition to the conventional Child-Pugh score. However, most surgical candidates present normal serum bilirubin level and indocyanine green clearance test is not common in most countries. Therefore, we sought to create a simple and broadly available risk prediction model using clinical parameters to estimate the surgical risk and survival outcomes after curative resection of HCC. Methods: We evaluated all consecutive patients from our institution who underwent curative resection of HCC between 1995 and 2013 (training set, n=889) and a new statistical model for risk estimation and survival outcomes was determined. The efficacy of the model was then validated using a recent prospective population (2014-2017) (validation set, n=310). Results: Multivariate analysis revealed that serum albumin level and platelet count are independent factors associated with patient prognosis, and following new statistical model (platelet-albumin score; PAL score) could be established: PAL score = -0.777 * Albumin (g/dL) - 0.575 * Log₁₀ (platelet count (10⁴/µL)) (cut-off value, -3.77 and -3.04). Receiver-operating curve analysis revealed that the PAL grade (area under the curve [AUC], 0.649) showed similar predictive power of patient survival compared with ALBI grade (AUC, 0.649) or ALICE grade (AUC, 0.678). Reproducibility of these results were confirmed in the validation set (AUC of 0.723, 0.743, and 0.784, respectively). In addition, PAL grade showed significant correlation with postoperative morbidity rate (grade 1, 14.0%; grade 2, 18.7%; grade 3, 26.1%, P=0.039) and incidence of refractory ascites (grade 1, 2.2%; grade 2, 7.1%; grade 3, 12.5%, P=0.005) in the training set. Similar outcomes were also confirmed in the validation set (postoperative morbidity rate, 13.3%, 23.1%, and 40.7%; P=0.003, and incidence of refractory ascites, 0.7%, 10.8%, and 22.2%; P<0.0001). Conclusions: PAL grade can be an alternative method to predict short-term surgical risk and long-term survival of patients undergoing curative resection of HCC.

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