Preoperative monocyte-to-albumin ratio predicts overall survival after hepatectomy for hepatocellular carcinoma: a single-center retrospective study

Background Hepatocellular carcinoma (HCC) is a major cause of cancer-related death worldwide. Hepatectomy is a potentially curative option for selected patients, but postoperative recurrence and death remain frequent. There is a need for simple, low-cost indices that can be measured before surgery to improve risk stratification. The monocyte-to-albumin ratio (MAR) reflects systemic inflammation and nutritional status. This study evaluated whether preoperative monocyte-to-albumin ratio predicts overall survival (OS) in patients with hepatocellular carcinoma undergoing hepatectomy and aimed to construct a prognostic nomogram incorporating this ratio for individualized survival estimation. Methods We retrospectively analyzed 539 consecutive patients with pathologically confirmed hepatocellular carcinoma who underwent curative-intent hepatectomy at Meizhou People’s Hospital between May 2011 and July 2023. Clinical characteristics, laboratory tests, tumor features, and survival data were obtained from medical records. Monocyte-to-albumin ratio was calculated as monocyte count × 1000 / albumin (g/dL). The optimal cut-off value was determined using R software. Overall survival was estimated by the Kaplan–Meier method and compared between groups using log-rank tests. Cox proportional hazards regression was used to identify independent prognostic factors. A prognostic nomogram was developed based on multivariable Cox analysis and internally assessed using the concordance index(C-index), time-dependent receiver operating characteristic curves(ROC), and calibration plots. Results Patients were classified into high and low monocyte-to-albumin ratio groups according to the optimal cut-off. Those with a high ratio had significantly shorter overall survival than those with a low ratio (log-rank p < 0.001). In multivariable Cox analysis, a lower monocyte-to-albumin ratio was independently associated with better overall survival after adjustment for standard clinicopathological variables (hazard ratio 0.58, 95% confidence interval 0.42–0.82, p < 0.001). The nomogram that combined monocyte-to-albumin ratio with other independent factors showed good discrimination and calibration, and provided higher prognostic accuracy than single predictors. Conclusions Preoperative MAR is an independent prognostic marker of OS in patients with HCC undergoing hepatectomy. A nomogram integrating this ratio with routine clinicopathological factors may offer a practical tool for individualized risk assessment and postoperative management.