title: Combined Hangzhou criteria with neutrophil-lymphocyte ratio is superior to other criteria in selecting liver transplantation candidates with HBV-related hepatocellular carcinoma.
abstract: BACKGROUND
  The elevation of neutrophil-lymphocyte ratio (NLR) has adverse effects on the prognosis of patients with hepatocellular carcinoma (HCC) who have received liver transplantation (LT). The Hangzhou criteria are set for selecting HCC patients for LT. The present study aimed to establish a set of new criteria combining the NLR and Hangzhou criteria for selecting HCC patients for LT.
  
  
  METHODS
  Receiver operating characteristic (ROC) analysis was done to determine the optimal NLR threshold. Univariate and multivariate analyses were made to evaluate the factors affecting the outcomes of HCC patients after LT. We also proposed new criteria consisting of the elevated NLR and Hangzhou criteria. ROC analysis was carried out to validate the feasibility of the new criteria.
  
  
  RESULTS
  Three hundred and five HCC patients were included in this study. The mean follow-up time of these patients was 5.4 years. Of the 305 patients, 197 (64.6%) showed elevated NLRs (NLR > 4). The recurrence-free survival rates of the patients with elevated NLRs at 1, 3 and 5 years were lower than those of the patients with normal NLRs (NLR ≤ 4) (50.1%, 21.7% and 20.2% vs 80.5%, 58.7% and 56.4%, respectively; P < 0.001). The overall survival rate was lower in the patients with elevated NLR than in those with normal NLR at 1, 3 and 5 years (60.8%, 27.0% and 22.5% vs 78.4%, 51.1% and 47.8%, respectively; P < 0.001). Multivariate analysis demonstrated that an NLR > 4 (P = 0.034), total tumor size > 8 cm (P = 0.005), alpha-fetoprotein level > 400 μg/L (P = 0.007) and the presence of vascular invasion (P = 0.003) were independent predictors of HCC recurrence in post-transplant patients. We proposed a set of new criteria based on the elevated NLR and Hangzhou criteria. A ROC analysis demonstrated that the patients with scores ≥ 1 had an area under the curve of 0.764.
  
  
  CONCLUSIONS
  The criteria combining the elevated NLR and Hangzhou criteria can be used to select patients with HCC for LT.
authors.affiliation: Liver Transplantation Center, West China Hospital, Sichuan University, Chengdu 610041, China. yanlunan688@163.com.
authors.forename: Guang-Qin
authors.initials: GQ
authors.lastname: Xiao
authors.forename: Jia-Yin
authors.initials: JY
authors.lastname: Yang
authors.forename: Lu-Nan
authors.initials: LN
authors.lastname: Yan
mesh_terms: D019540:Area Under Curve; D006528:Carcinoma, Hepatocellular / Q000097:blood / Q000175:diagnosis / Q000401:mortality / Q000601:surgery* / Q000821:virology; D016009:Chi-Square Distribution; D003661:Decision Support Techniques; D018450:Disease Progression; D018572:Disease-Free Survival; D005240:Feasibility Studies; D005260:Female; D006509:Hepatitis B / Q000150:complications* / Q000175:diagnosis / Q000401:mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008113:Liver Neoplasms / Q000097:blood / Q000175:diagnosis / Q000401:mortality / Q000601:surgery* / Q000821:virology; D016031:Liver Transplantation / Q000009:adverse effects / Q000401:mortality; D018655:Lymphocyte Count; D008214:Lymphocytes; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009361:Neoplasm Invasiveness; D009364:Neoplasm Recurrence, Local; D009504:Neutrophils; D018579:Patient Selection; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D012372:ROC Curve; D012042:Registries; D015203:Reproducibility of Results; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D047368:Tumor Burden; D000509:alpha-Fetoproteins / Q000032:analysis
chemical_list: C097353:AFP protein, human; D000509:alpha-Fetoproteins