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Multicenter Study
. 2016 Jul 19;11(7):e0159530.
doi: 10.1371/journal.pone.0159530. eCollection 2016.

Assessment of Preoperative Liver Function in Patients with Hepatocellular Carcinoma - The Albumin-Indocyanine Green Evaluation (ALICE) Grade

Takashi Kokudo  1   2 , Kiyoshi Hasegawa  1 , Katsumi Amikura  2 , Emilie Uldry  3 , Chikara Shirata  1 , Takamune Yamaguchi  1 , Junichi Arita  1 , Junichi Kaneko  1 , Nobuhisa Akamatsu  1 , Yoshihiro Sakamoto  1 , Amane Takahashi  2 , Hirohiko Sakamoto  2 , Masatoshi Makuuchi  4 , Yutaka Matsuyama  5 , Nicolas Demartines  3 , Massimo Malagó  6 , Norihiro Kokudo  1 , Nermin Halkic  3
Affiliations
Multicenter Study

Assessment of Preoperative Liver Function in Patients with Hepatocellular Carcinoma - The Albumin-Indocyanine Green Evaluation (ALICE) Grade

Takashi Kokudo et al. PLoS One. .

Abstract

Background: Most patients with hepatocellular carcinoma (HCC) have underlying liver disease, therefore, precise preoperative evaluation of the patient's liver function is essential for surgical decision making.

Methods: We developed a grading system incorporating only two variables, namely, the serum albumin level and the indocyanine green retention rate at 15 minutes (ICG R15), to assess the preoperative liver function, based on the overall survival of 1868 patients with HCC who underwent liver resection. We then tested the model in a European cohort (n = 70) and analyzed the predictive power for the postoperative short-term outcome.

Results: The Albumin-Indocyanine Green Evaluation (ALICE) grading system was developed in a randomly assigned training cohort: linear predictor = 0.663 × log10ICG R15 (%)-0.0718 × albumin (g/L) (cut-off value: -2.20 and -1.39). This new grading system showed a predictive power for the overall survival similar to the Child-Pugh grading system in the validation cohort. Determination of the ALICE grade in Child-Pugh A patients allowed further stratification of the postoperative prognosis. This result was reproducible in the European cohort. Determination of the ALICE grade allowed better prediction of the risk of postoperative liver failure and mortality (ascites: grade 1, 2.1%; grade 2, 6.5%; grade 3, 16.0%; mortality: grade 1, 0%; grade 2, 1.3%; grade 3, 5.3%) than the previously reported model based on the presence/absence of portal hypertension.

Conclusions: This new grading system is a simple method for prediction of the postoperative long-term and short-term outcomes.

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Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. Overall survival according to the Albumin-Indocyanine Green Evaluation (ALICE) grade in the Japanese training cohort.
Numbers below the x-axis indicate the number of patients at risk.
Fig 2
Fig 2. Overall survival according to the Child-Pugh grade in the Japanese training cohort.
Numbers below the x-axis indicate the number of patients at risk.
Fig 3
Fig 3. Overall survival according to the Albumin-Indocyanine Green Evaluation (ALICE) grade in the Japanese validation cohort.
Numbers below the x-axis indicate the number of patients at risk.
Fig 4
Fig 4. Overall survival according to the Child-Pugh grade in the Japanese validation cohort.
Numbers below the x-axis indicate the number of patients at risk.
Fig 5
Fig 5. ROC curve of Albumin-Indocyanine Green Evaluation (ALICE) score in the Japanese training cohort.
Fig 6
Fig 6. Overall survival according to the Albumin-Indocyanine Green Evaluation (ALICE) grade in the European cohort.
Numbers below the x-axis indicate the number of patients at risk.
Fig 7
Fig 7. Overall survival according to the Albumin-Indocyanine Green Evaluation (ALICE) grade in a Japanese Child-Pugh A validation cohort.
Numbers below the x-axis indicate the number of patients at risk.
Fig 8
Fig 8. Overall survival based on the presence/absence of portal hypertension (PH) in a Japanese Child-Pugh A validation cohort.
Numbers below the x-axis indicate the number of patients at risk.
Fig 9
Fig 9. Heat map showing the Albumin-Indocyanine Green Evaluation (ALICE) grade.
ALICE grade 1: green, ALICE grade 2a: yellow a, ALICE grade 2b: yellow b, ALICE grade 3: red.
Fig 10
Fig 10. Incidence of ascites and mortality rate according to the Albumin-Indocyanine Green Evaluation (ALICE) grade.
Fig 11
Fig 11. Proposed surgical treatment strategy for hepatocellular carcinoma patients according to the Albumin-Indocyanine Green Evaluation (ALICE) grade.
See this image and copyright information in PMC

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