Prognostic significance of neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios in hepatocellular carcinoma: a retrospective multicenter study on overall and recurrence-free survival following liver resection or liver transplantation

Background Systemic inflammation plays a critical role in hepatocellular carcinoma (HCC) progression and postoperative outcomes. This study assessed the prognostic value of the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) for overall (OS) and recurrence-free survival (RFS) in patients undergoing curative hepatectomy or orthotopic liver transplantation (OLT). Methods In this multicenter retrospective cohort of 74 HCC patients (86.5% male; median age 68.0 years), NLR and PLR were evaluated preoperatively and at 1-, 3-, 6-, and 12-months post-surgery. Associations with OS and RFS were evaluated using univariate, multivariable, and Cox proportional hazards models with time-varying covariates, while model discrimination was assessed using Harrell’s concordance index. Results Elevated preoperative PLR predicted major postoperative complications (AUROC = 0.667, p = 0.030). The 3-month NLR demonstrated strong discriminative performance for OS (C-index 0.79). In time-varying Cox models, postoperative NLR emerged as a robust, time-independent predictor of OS (HR 1.35; p = 0.033), independent of the surgical procedure and Barcelona Clinic Liver Cancer stage. Multivariable analyses demonstrated that elevated NLR at 3-, 6-, and 12-months and PLR at 12 months independently predicted reduced OS. Hepatectomy was the dominant determinant of reduced RFS compared with OLT (p < 0.001), while an NLR threshold >2.5 identified a subgroup at markedly increased mortality risk, particularly following hepatectomy. Conclusions Postoperative NLR is a powerful, time-independent prognostic biomarker for OS in surgically treated HCC, especially after liver resection, while PLR provides complementary prognostic information. These findings support the clinical integration of inflammation-based biomarkers into postoperative risk stratification and surveillance strategies.