Introduction
Variceal bleeding in hepatocellular carcinoma (HCC) patients is related to a poor prognosis. Therefore, identifying high-risk varices (HRV) in HCC patients is crucial. Unlike in cirrhosis, where Baveno VII uses non-invasive tests to rule out HRV, this approach doesn't extend to HCC. Our study aims to validate and refine the previously studied Albumin-bilirubin and platelet (ALBI-PLT) score for predicting HRV in HCC.

Methods
HCC patients who had EGD report without prior upper GI bleeding at King Chulalongkorn Memorial Hospital from 2019 to 2023 were included in the study. We retrospectively assessed clinical data and liver function tests recorded three months before EGD. HRV was defined by the F2 or F3 esophageal varices on EGD. An ALBI-PLT score was computed following Chen et al. (1) Modified ALBI-PLT (mALBI-PLT) calculated from mALBI grading (1 point for grade 1 or 2a; 2 points for grade 2b or 3) and platelet (1 point for > 150,000/µL; 2 points for ≤150,000/µL).

Results
Of 579 HCC patients, 277 were included in our study. The mean age of participants was 66.42 years, and 215 (77.6%) were male. Most patients had Child-Turcotte-Pugh A cirrhosis of 232 (83.8%), while 131 (47.3%), 85 (30.7%), and 60 (22.0%) had HCC stages BCLC A, B, and C. Of these patients, 22 (7.9%), 56 (20.2%), 147 (53.1%), and 52 (18.8%) fell into mALBI grades 1, 2a, 2b, and 3. 38 (15.6%) of participants had HRV on EGD. The AUROC of the ALBI score and platelet for predicting HRV were 0.755 (0.681-0.829), p < 0.001 and 0.738 (0.641-0.835), p<0.001. On multivariate analysis, platelet ≤150,000/µL and mALBI grade 2b and 3 were significantly associated with HRV with an adjusted odd ratio of 4.29 (1.79-10.27), p < 0.001 and 3.72 (1.08-12.81), p 0.005. (Table 1) ALBI-PLT and mALBI-PLT scores >2 demonstrated excellent sensitivity of 100% and 97.37%, with a negative predictive value (NPV) of 100% and 98.18% in predicting HRV. (Table 2)

Conclusion
mALBI grade and platelet at cut-off 150,000/µL exhibited significant association with HRV in patients with HCC. In addition, HCC patients with mALBI grade 1 or 2a, together with platelet > 150,000/µL may be able to avoid EGD.

Reference
1.Chen PH, Hsieh WY, Su CW, Hou MC, Wang YP, Hsin IF, et al. Combination of albumin-bilirubin grade and platelets to predict a compensated patient with hepatocellular carcinoma who does not require endoscopic screening for esophageal varices. Gastrointest Endosc. 2018;88(2):230-9.e2.

<b>Table 1</b> The uni- and multivariate analysis of factors associated with high-risk varices in HCC patients.

Table 1 The uni- and multivariate analysis of factors associated with high-risk varices in HCC patients.

<b>Table 2</b> the sensitivity, specificity, positive predictive value and negative predictive value of each cut off of ALBI-PLT and mALBI-PLT scores for predicting high risk varices in HCC.

Table 2 the sensitivity, specificity, positive predictive value and negative predictive value of each cut off of ALBI-PLT and mALBI-PLT scores for predicting high risk varices in HCC.

Sirinporn Suksawatamnuay

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