Albumin-Bilirubin Grade and Hepatocellular Carcinoma Treatment Algorithm

The selection of treatment options for hepatocellular carcinoma (HCC) requires critical consideration of hepatic functional reserve in addition to tumor burden (e.g., size and number of HCC nodules [tumor node metastasis stage]). Presently, the Child-Pugh classification is the most common worldwide measure used to assess hepatic functional reserve for the selection of treatment options for HCC [1] . The Child-Pugh classification is used in the American (AASLD [2] ), European (EASL-EORTC [3] ), Asian (APASL [4] ), and Japanese (consensus-based [5, 6] and evidence-based [7–9] ) guidelines. However, there are several issues associated with the Child-Pugh scoring system. First, it includes the subjective criteria of hepatic encephalopathy and ascites in addition to albumin and bilirubin levels. Second, the classification of albumin levels and ascites together is not adequate because they are interrelated factors. Furthermore, converting prothrombin time into the international normalized ratio produces a score of 1 in many patients. Nonetheless, the Child-Pugh score remains the standard measure for selecting treatment options for HCC in clinical practice and clinical trials. In Japan, a classification called the liver damage grade, which was developed by the Liver Cancer Study Group of Japan (LCSGJ), has been used historically instead of the Child-Pugh score [10] . This classification resembles the Child-Pugh classification but replaces 1 of the 5 factors (hepatic encephalopathy) by the results from the indocyanine green retention test at Published online: March 9, 2017 www.karger.com/lic DOI: 10.1159/000462199