Prognostic Value of Neutrophil-to-Lymphocyte Ratio Across Barcelona Clinic Liver Cancer Stages in Hepatocellular Carcinoma: A Multicenter Retrospective Analysis

Abstract Hepatocellular carcinoma (HCC) is the 6th most common malignancy worldwide with variable prognostic outcomes. The neutrophil-to-lymphocyte ratio (NLR) has emerged as a potential prognostic marker, but its applicability across BCLC stages remains unclear. This study aims to assess the prognostic value of NLR in patients with HCC across different BCLC stages. We conducted a multicenter retrospective analysis of 312 HCC patients diagnosed between 2010 and 2016. Patients were divided into BCLC stages 0-A, B, and C and further stratified by NLR < 1.5 and NLR ≥ 1.5. Overall survival (OS) and progression-free survival (PFS) were analyzed, with comparisons across stages and NLR subgroups. Patients with NLR < 1.5 were trending toward improved OS in each BCLC stage, with significant differences observed in stages B and C. In BCLC stage B, NLR < 1.5 was associated with a twofold increase in PFS compared to NLR ≥ 1.5. BCLC stage C patients with NLR < 1.5 achieved OS outcomes comparable to BCLC stage B patients with NLR ≥ 1.5. Although limited by sample size and heterogeneity in treatment modalities, these findings suggest NLR as a relevant prognostic factor across HCC stages. In conclusion, lower NLR was associated with better survival outcomes across BCLC stages, supporting its use as a prognostic marker in HCC. Future prospective studies are needed to confirm these findings and to determine optimal NLR cut-offs for clinical practice.