Inflammation-based scores and hepatocellular carcinoma - authors' reply

Abstract

TO THE EDITORS:We thank Lai and Lerut for their interest in our data and their comments regarding the role of inflammation scores in predicting post-liver transplantation (LT) hepatocellular carcinoma (HCC) recurrence, and we would like to add a few more points to this fruitful discussion. In our study, 1 in partial discordance with previously published data, the neutrophil-to-lymphocyte ratio (NLR) and other inflammation-based scores did not predict post-LT HCC recurrence, and this implied that such scores are not useful predictive tools for patients receiving transplants within the Milan criteria. Moreover, inflammation-based scores were not associated with any tumor-related parameters (ie, total tumor size, size of largest lesion, number of tumor lesions, and discrepancy between radiological and explant histological evaluations regarding fulfillment of the Milan criteria). Lai and Lerut suggest that inflammationbased scores might be relevant for patients receiving transplants outside the Milan criteria and hence for bigger tumors that are more biologically active.Interestingly, 2 studies have shown an association between the pre-LT NLR and HCC recurrence, 2,3 and 2 have not. 4,5 In all studies, 2-5 approximately 30% of the patients were outside the Milan criteria; however, there was no analysis of inflammatory markers in association with these criteria apart from 1 study. 2 In that study, patients outside the Milan criteria with high NLRs had significantly worse tumor-free survival than those with low NLRs. 2 In the study by Lai et al., 4 the NLR predicted waiting-list dropout but failed to predict HCC recurrence in patients receiving transplants.In the current era of careful selection of LT candidates and strict adherence to the Milan criteria, we believe that inflammation-based scores do not have a role in patients listed for LT. Neoadjuvant treatment for patients on the waiting list 6 and minimization of the dosage of calcineurin inhibitors after LT 7 are far more important ways of reducing the recurrence risk.