Combined preoperative PNI and APRI for risk stratification after curative hepatectomy for hepatocellular carcinoma

Long-term outcomes after curative hepatectomy for hepatocellular carcinoma (HCC) remain heterogeneous, yet simple preoperative tools for postoperative risk stratification are limited. We investigated whether combining representative inflammation/nutrition- and fibrosis-related markers could improve pragmatic risk stratification after hepatectomy.

We retrospectively analyzed 343 consecutive patients who underwent curative hepatectomy for primary HCC between June 2010 and November 2020 at a single tertiary center. Preoperative laboratory data obtained within 4 weeks before surgery were used to calculate candidate inflammation-based scores and fibrosis markers. Cut-offs were derived using receiver operating characteristic analysis for 5-year mortality. Overall survival (OS) and recurrence-free survival (RFS) were assessed using Kaplan-Meier methods and Cox proportional hazards models adjusted for a prespecified clinical covariate set. Discrimination, calibration, and bootstrap internal validation were also evaluated.

In separate multivariable models using the same clinical adjustment set, low prognostic nutritional index (PNI) and high aspartate aminotransferase-to-platelet ratio index (APRI) were independently associated with worse OS and RFS. A combined PNI-APRI classification stratified patients into low-, intermediate-, and high-risk groups with 5-year OS rates of 82.5%, 74.5%, and 49.7%, respectively, and 5-year RFS rates of 47.7%, 38.2%, and 18.6%, respectively. Compared with the low-risk group, the adjusted hazard ratio for the high-risk group was 2.72 for OS and 2.12 for RFS. Adding the composite classification to the base clinical model improved the C-index from 0.703 to 0.722 for OS and from 0.634 to 0.648 for RFS. Calibration was acceptable, and optimism-corrected C-index values after bootstrap internal validation were 0.705 for OS and 0.633 for RFS.

Preoperative PNI and APRI captured complementary host domains and, when combined, provided a simple classification associated with both OS and RFS after curative hepatectomy for HCC. Pending external validation, this routine laboratory-based approach may serve as a simple adjunct to existing clinical assessment when planning perioperative optimization and postoperative follow-up.