Platelet count as a double-edged sword: The impact of thrombocytosis and thrombocytopenia on long-term outcomes after hepatic resection for hepatocellular carcinoma

The prognostic significance of preoperative platelet counts among patients with hepatocellular carcinoma (HCC) undergoing curative resection remains controversial. The objective of the current study was to investigate the impact of preoperative platelet count on long-term outcomes after HCC resection. Patients who underwent curative-intent resection for HCC between 2000 and 2021 at 10 hepatobiliary centers in China were retrospectively analyzed. Patients were categorized based on platelet count within 2 weeks before surgery: thrombocytopenia (< 100 × 10⁹/L), normal platelet count (100-299 × 10⁹/L), and thrombocytosis (≥ 300 × 10⁹/L). The primary outcomes were overall survival (OS) and recurrence-free survival (RFS). Among 3,116 patients, 655 (21.0%) had thrombocytopenia, 2,374 (76.2%) had normal platelet counts, and 87 (2.8%) had thrombocytosis. The 5-year OS was 52.7%, 56.0%, and 40.2% for thrombocytopenia, normal platelet count, and thrombocytosis groups, respectively (p < 0.001 among the three groups); the corresponding 5-year RFS was 39.3%, 39.3%, and 26.9%, respectively (p = 0.001 among the three groups). Multivariable analysis identified both thrombocytopenia (HR 1.215, 95% CI 1.045-1.413, p = 0.011) and thrombocytosis (HR 1.307, 95% CI 1.130-1.511, p < 0.001) as independent risk factors for worse OS, and thrombocytosis was independently associated with worse RFS (HR 1.523, 95% CI 1.196-1.939, p = 0.001). Both thrombocytopenia and thrombocytosis were associated with worse survival after HCC resection, with thrombocytosis also predicting higher risk of recurrence. Routine preoperative platelet count may serve as a valuable and practical prognostic marker for risk stratification among patients with HCC undergoing resection.