title: Importance of low preoperative platelet count in selecting patients for resection of hepatocellular carcinoma: a multi-institutional analysis.
abstract: BACKGROUND
  Low platelet count is a marker of portal hypertension but is not routinely included in the standard preoperative evaluation of patients with hepatocellular carcinoma (HCC) because it pertains to liver function (Child/model for end-stage liver disease [MELD] score) and tumor burden (Milan criteria). We hypothesized that low platelet count would be independently associated with increased perioperative morbidity and mortality after resection.
  
  
  METHODS
  Patients treated with liver resection for HCC between January 2000 and January 2010 at 3 institutions were eligible. Preoperative platelet count, Child/MELD score, and tumor extent were recorded. Low preoperative platelet count (LPPC) was defined as <150 × 10(3)/μL. Postoperative liver insufficiency (PLI) was defined as peak bilirubin >7 mg/dL or development of ascites. Univariate and multivariate regression was performed for predictors of major complications, PLI, and 60-day mortality.
  
  
  RESULTS
  A total of 231 patients underwent resection, of whom 196 (85%) were classified as Child A and 35 (15%) as Child B; median MELD score was 8. Overall, 168 (71%) had tumors that exceeded Milan criteria and 134 (58%) had major hepatectomy (≥3 Couinaud segments). Overall and major complication rates were 55% and 17%, respectively. PLI occurred in 25 patients (11%), and 21 (9%) died within 60 days of surgery. Patients with LPPC (n = 50) had a significantly increased number of major complications (28% versus 14%, p = 0.031), PLI (30% versus 6%, p = 0.001), and 60-day mortality (22% versus 6%, p = 0.001). When adjusted for Child/MELD score and tumor burden, LPPC remained independently associated with increased number of major complications (odds ratio [OR] 2.8, 95% confidence intervals [CI] 1.1 to 6.8, p = 0.026), PLI (OR 4.0, 95% CI 1.4 to 11.1, p = 0.008), and 60-day mortality (OR 4.6, 95% CI 1.5 to 14.6, p = 0.009).
  
  
  CONCLUSIONS
  LPPC is independently associated with increased major complications, PLI, and mortality after resection of HCC, even when accounting for standard criteria, such as Child/MELD score and tumor extent, used to select patients for resection. Patients with LPPC may be better served with transplantation or liver-directed therapy.
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia 30322, USA. smaithe@emory.edu
authors.forename: Shishir K
authors.initials: SK
authors.lastname: Maithel
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Kneuertz
authors.forename: David A
authors.initials: DA
authors.lastname: Kooby
authors.forename: Charles R
authors.initials: CR
authors.lastname: Scoggins
authors.forename: Sharon M
authors.initials: SM
authors.lastname: Weber
authors.forename: Robert C G
authors.initials: RC
authors.lastname: Martin
authors.forename: Kelly M
authors.initials: KM
authors.lastname: McMasters
authors.forename: Clifford S
authors.initials: CS
authors.lastname: Cho
authors.forename: Emily R
authors.initials: ER
authors.lastname: Winslow
authors.forename: William C
authors.initials: WC
authors.lastname: Wood
authors.forename: Charles A
authors.initials: CA
authors.lastname: Staley
mesh_terms: D000328:Adult; D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000097:blood* / Q000601:surgery*; D015331:Cohort Studies; D005260:Female; D006498:Hepatectomy; D006801:Humans; D008113:Liver Neoplasms / Q000097:blood* / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D010976:Platelet Count; D011237:Predictive Value of Tests; D057234:Preoperative Period; D012189:Retrospective Studies; D016896:Treatment Outcome; D055815:Young Adult