Importance of Low Preoperative Platelet Count in Selecting Patients for Resection of Hepatocellular Carcinoma: A Multi-Institutional Analysis

• Authors: Shishir Kumar Maithel, Emory University; Peter J Kneuertz, Emory University; David A Kooby, Emory University; Charles R Scoggins, University of Louisville; Sharon M Weber, University of Wisconsin-Madison; Robert CG Martin, University of Louisville; Kelly M McMasters, University of Louisville; Clifford S Cho, University of Wisconsin-Madison; Emily R Winslow, University of Wisconsin-Madison; William C Wood, Emory University; Charles Staley, Emory University
• Journal Title: Journal of The American College of Surgeons
• Volume: Volume 212, Number 4
• Publisher: Elsevier: 12 months | 2011-04, Pages 638-650
• Type of Work: Article | Post-print: After Peer Review
• Publisher DOI: http://doi.org/10.1016/j.jamcollsurg.2011.01.004
• Subjects: Health Sciences, Medicine and Surgery; Health Sciences, Oncology

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. Study Design: 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 × 103/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.