Child-Pugh Score Should Be Determined for Metastatic Liver Disease
Yes, the Child-Pugh score should be determined for patients with metastatic liver disease, not just primary liver cancer—it is a fundamental assessment of hepatic functional reserve that guides treatment decisions and predicts outcomes regardless of whether the liver pathology is primary or metastatic. 1, 2, 3
Rationale for Universal Application
The Child-Pugh score assesses hepatic functional reserve, not the etiology of liver disease. 1, 2 The score evaluates five parameters (bilirubin, albumin, INR/PT, ascites, and encephalopathy) that reflect liver function independent of whether dysfunction stems from cirrhosis, primary hepatocellular carcinoma, or metastatic infiltration. 2, 3
Key Clinical Applications in Metastatic Disease
Surgical candidacy assessment: The Child-Pugh score determines eligibility for hepatic resection of metastases, with only Child-Pugh Class A patients (and highly selected Class B patients with normal liver function tests and no portal hypertension) being candidates for surgery. 1
Radiation therapy planning: In stereotactic body radiation therapy (SBRT) for liver metastases, baseline Child-Pugh classification predicts risk of hepatic decompensation, with approximately 22% of patients experiencing Child-Pugh class decline after treatment. 4, 5
Medication dosing: The Child-Pugh score guides dosing adjustments for chemotherapy and targeted agents in patients with hepatic impairment from any cause, including metastatic infiltration. 2, 6
Prognostic Significance Across Etiologies
The Child-Pugh classification provides critical prognostic information regardless of liver disease etiology:
- Class A (5-6 points): Compensated function, 90% 5-year survival 3
- Class B (7-9 points): Decompensated function, 68% 7-year survival 2
- Class C (10-15 points): Severely decompensated, 25% 7-year survival 2
These survival estimates apply broadly to hepatic dysfunction, whether from cirrhosis, primary malignancy, or metastatic burden. 2, 3
Essential Complementary Assessments
Beyond the Child-Pugh score, evaluate for clinically significant portal hypertension (esophagogastric varices, splenomegaly, thrombocytopenia, abdominal collaterals), as this is not captured by the score but critically impacts surgical risk and prognosis. 1, 3
For patients being considered for liver-directed therapies (resection, ablation, SBRT), calculate the future liver remnant ratio (FLR/total liver volume), which should be ≥20% in patients with normal liver function. 1
Important Caveats
In metastatic breast cancer specifically, some oncologists prefer using liver function tests (LFTs) rather than Child-Pugh score for dosing decisions, as metastatic infiltration may not cause the same pattern of dysfunction as cirrhosis. 6
The Child-Pugh score has limitations including subjective components (ascites, encephalopathy grading) and lack of renal function assessment—consider also calculating MELD score for comprehensive evaluation. 1, 3
The score does not capture temporary decompensating events and has limited dynamic range, but remains the most practical bedside tool for hepatic reserve assessment. 2, 3