Reply to 'Comment on 'Transarterial chemo-embolisation of hepatocellular carcinoma: impact of liver function and vascular invasion' '.

Sir,

We appreciate (Huo interest in our paper (Waked ). We agree with them that the ALBI score (Johnson ) has proved in >100 recent publications to be a robust refinement of the conventional Child–Pugh–Turcotte (CPT) classification among patients with hepatocellular carcinoma (HCC). As Huo et al point out, the next step would be to integrate the ALBI score into the current HCC staging systems. The theoretical base for such considerations has already been presented by Chan et al (2016a, b, 2017), who have demonstrated that when ALBI is substituted for CPT in BCLC, CLIP or the Japanese Integrated System, their prognostic performance does not deteriorate and may be enhanced. While this may support more routine use of the ALBI system, particularly given its complete objectivity, simplicity and that its application is not confined to patients with cirrhosis, CPT remains deeply embedded in the hepatological culture and only time will tell if the benefits of ALBI will prove strong enough to challenge CPT.

The further enhancement of ALBI to PALBI by the addition of platelet (P) count does indeed appear to be a significant advance (Roayaie ; Huo, 2017). Just why and how the combination of the three simple and routine tests of serum bilirubin, serum albumin and the platelet count have proved to be of such exquisite prognostic performance has not been addressed in any detail. Further insight may come from comparative studies in patients with chronic liver disease without HCC, but the mechanistic underpinning of ALBI and PALBI is unlikely to be as simple as implied by the conventional interpretation of the individual tests.