Introduction Hepatocellular carcinoma HCC is the fifth most
Hepatocellular carcinoma (HCC) is the fifth most lethal malignant tumor worldwide and is the second leading cause of cancer-related death . For HCC patients, ctab medical abbreviation receptor virus (HBV) infection is the important causative risk factor in Asia-Pacific regions [, , ]. In China, more than 90% HCC patients are infected with HBV .
Although there are many effective treatments for HCC, surgical resection remains the only radical therapy at present . Despite tremendous improvements in preoperative diagnosis, surgical techniques, and radiofrequency ablation procedures for HCC, overall survival (OS) of HCC patients remains unsatisfactory  mainly due to the high recurrence rate . We previously found that postoperative HBV reactivation (PHR) was the independent risk factor of HCC recurrence . Ample evidence has shown that antiviral therapy could significantly reduce the incidence of PHR and the HCC recurrence rate [10,11], but antiviral therapy is only available for patients with high HBV-DNA levels (>103 copies/ml) according to the guidelines and large sample studies [12,13]. Antiviral therapy is not usually recommended for HCC patients with low HBV-DNA levels (<103 copies/ml) and the incidence of PHR is not that rare . The exact mechanism of how PHR occurs is not clear, though our previous finding suggested that PHR may be associated with resection-induced immunosuppression in patients with HBV-related HCC .
Malnutrition is frequent noticed in different cancer patients, and HCC patients are at a special increased risk for malnutrition [15,16]. It was reported that 30–40% HCC patients presented with varying degrees of malnutrition . Studies have demonstrated that HCC patients with the impaired nutritional status such as lower body mass index (BMI), hypoalbuminemia or ascites are often accompanied with poor survival outcomes [, , ]. However, no current recommendation is available to assess the nutritional status for HCC patients. Therefore, the development of methods to evaluate the nutritional status and predict clinical outcome of HCC patients is of considerable significance. Controlling Nutritional Status (CONUT) score, which consists of the serum albumin (ALB) concentration, total lymphocyte count (TLC), and total cholesterol (TC) concentration , has been widely used in evaluating nutrition status and predict the clinical outcome of many malignancies [, , ].
We previously found that the immune function in patients with PHR was impaired , and CONUT score has proved to be a good tool to assess the immune-nutritional status [23,25]. But whether HCC patients with malnutrition were more likely to develop PHR remained ambiguous. In vernalization study, we enrolled resectable HCC patients with low HBV-DNA levels (<103 copies/ml) without receiving preoperative antiviral therapy, and analyzed the relation between the immune-nutritional status and the incidence of PHR, in an attempt to explore the predictive value of COUNT score in the enrolled resectable HCC patients with low HBV-DNA levels.
Patients and methods
Discussion Our previous study suggested that PHR may be associated with resection-induced immunosuppression in patients with HBV-related HCC . Malnutrition is common in HCC patients , and believed to be associated with impaired immune function . But the relation between PHR and immune-nutritional function remains unknown. CONUT score consists of both immune and nutritional indicators and may serve as a detector of predicting PHR in HBV-related HCC. Thus, we conducted this study by enrolling HBV-related HCC patents with low HBV-DNA levels and analyzed short/long-term outcomes in patients with different CONUT scores. It was found that OS and RFS were significantly worse in patients with high CONUT score. In addition, HCC patients with high CONUT score had a higher incidence of postoperative complications and were more likely to develop PHR, indicating that CONUT score had a strong relation with PHR. Subgroup analysis further proved that COUNT score was more effective to predict PHR in patients with HBV-DNA levels<500 copies/ml than patients with HBV-DNA 500–1000 copies/ml.