Development and validation of the APASL score: A laboratory-based prognostic model for survival prediction in patients undergoing hepatectomy for hepatocellular carcinoma.

BACKGROUND: Precise preoperative risk stratification is critical for hepatocellular carcinoma (HCC) patients undergoing hepatectomy. This multicenter study aimed to develop and validate a laboratory-based prognostic score for survival prediction in patients undergoing hepatectomy for HCC. METHODS: Patients who underwent curative hepatectomy between January 2015 and December 2022 from six hospitals were divided into the training and validation cohorts. Preoperative laboratory parameters were analyzed by univariate and multivariate Cox regression. Based on alpha-fetoprotein (AFP, A), protein induced by vitamin K absence or antagonist-II (PIVKA-II, P), albumin (ALB, A), aspartate aminotransferase (AST, S), and total bilirubin (TBIL, L), we constructed a prognostic model named APASL. The prognostic performance was assessed using concordance index (C-index), time-dependent receiver operating characteristic curves, and calibration plots. RESULTS: A total of 1669 patients undergoing curative hepatectomy for HCC were included, 1239 as the training cohort and 430 as the validation cohort. The APASL score showed strong prognostic performance, with C-indices of 0.702 and 0.706 for predicting 5-year survival in the training and validation cohorts, respectively. X-tile analysis identified an optimal cutoff of 1.6, effectively separating patients into low-risk (≤ 1.6) and high-risk (> 1.6) groups, with significant differences in 5-year survival rates (61.4% vs. 37.2%, P < 0.001). The APASL score demonstrated superior predictive accuracy compared with conventional staging systems (TNM, BCLC, CLIP and Milan) and liver-function-based scores (ALBI and APRI). Multivariate Cox analysis confirmed that a high APASL score (> 1.6) was independently associated with decreased overall survival (hazard ratio: 1.248, 95% confidence interval: 1.036-1.502, P = 0.019). CONCLUSIONS: The APASL score provides an effective, exclusively laboratory-based prognostic tool for predicting long-term survival after hepatectomy for HCC. This straightforward scoring system facilitates objective preoperative risk assessment without requiring histopathologic information, potentially improving surgical decision-making and patient counseling for patients with HCC.