经肝动脉化疗栓塞术治疗伴门静脉癌栓肝细胞癌的效果及预后评价模型分析

目的探讨肝细胞癌(HCC)合并门静脉癌栓患者采用经肝动脉化疗栓塞术(TACE)治疗的效果,并评估现有肝癌预后评价模型的指导价值。方法筛选2010年1月—2016年5月在全国24家三级医院行TACE治疗的HCC患者,最终共纳入266例合并门静脉癌栓的HCC患者进行回顾性分析。采用Kaplan-Meier法绘制生存曲线,并采用log-rank法进行比较;采用Cox回归分析进行单因素和多因素分析,建立Cox回归模型;计算HAP评分、mHAP评分、mHAP2评分、mHAP3评分及6&12标准的受试者工作特征曲线下面积(AUC)和C指数,比较各种模型的预测性能。结果所纳入患者中位生存时间为9.867个月,根据Child-Pugh分级,Child-Pugh A级患者中位生存时间为10.067个月,明显长于Child-Pugh B级患者的5.967个月(χ2=5.181,P=0.023)。AFP≤800 ng/ml的患者中位生存时间13.10个月,而AFP>800/ml的患者中位生存时间8.13个月,差异有统计学意义(χ2=8.643,P=0.003)。单因素分析结果显示肿瘤数目、肿瘤直径、总胆红素、血清白蛋白、AST、ALT与患者的生存有关(P值均<0.05)。多因素分析结果显示肿瘤数目(HR=1.186,95%CI:1.058~1.329,P<0.05)、肿瘤直径(HR=1.047,95%CI:1.001~1.095,P<0.05)是影响患者生存的独立影响因素。6&12标准的1年、2年、3年AUC分别为0.651、0.655、0.641,高于其他模型,而6&12标准和新建模型的C指数分别为0.577和0.579,高于其他模型。结论在AFP水平较低、肝功能良好的HCC合并门静脉癌栓患者中,TACE是安全有效的。肿瘤直径和肿瘤数目为筛选合适的患者行TACE治疗提供了可靠依据。现有的原发性肝癌TACE治疗的预后评价模型中,6&12标准具有较好的预测能力。

Clinical effect of transcatheter arterial chemoembolization in treatment of patients with hepatocellular carcinoma and portal vein tumor thrombus and an analysis of prognostic evaluation models

Objective To investigate the clinical effect of transcatheter arterial chemoembolization(TACE)in the treatment of patients with hepatocellular carcinoma(HCC)and portal vein tumor thrombus and the value of existing prognostic evaluation models for HCC.MethodsScreening was performed for HCC patients who underwent TACE in 24 tertiary hospitals in China from January 2010 to May 2016,and finally 266 HCC patients with portal vein tumor thrombus were included for retrospective analysis.The Kaplan-Meier method was used to plot survival curves and the log-rank test was used for comparison;a Cox regression analysis was used to perform univariate and multivariate analyses and establish a Cox regression model;area under the ROC curve(AUC)and C-index were calculated for HAP score,mHAP score,mHAP2 score,mHAP3 score,and 6&12 criteria to compare their prediction performance.Results The median survival time was 9.867 months for all patients,and according to Child-Pugh class,the patients with Child-Pugh class A HCC had a significantly longer median survival time than those with Child-Pugh class B HCC(10.067 months vs 5.967 months,χ2=5.181,P=0.023).The patients with alpha-fetoprotein(AFP)≤800 ng/ml had a significantly longer median survival time than those with AFP>800 ng/ml(13.10 months vs 8.13 months,χ2=8.643,P=0.003).The univariate analysis showed that number of tumors,tumor diameter,total bilirubin,serum albumin,alanine aminotransferase(AST),and alanine aminotransferase(ALT)were associated with the survival of patients(all P<0.05),and the multivariate analysis showed that number of tumors(hazard ratio[HR]=1.186,95%confidence interval[CI]:1.058-1.329,P<0.05)and tumor diameter(HR=1.047,95%CI:1.001-1.095,P<0.05)were independent influencing factors for the survival of patients.The 1-,2-,and 3-year AUCs of 6&12 criteria were 0.651,0.655,and 0.641,respectively,which were higher than those of the other models;6&12 criteria and the new model had a C-index of 0.577 and 0.579,respectively,which were higher than C-index of the other models.Conclusion TACE is safe and effective in HCC patients with portal vein tumor thrombus who have a low AFP level and good liver function.Tumor diameter and number of tumors provide a reliable basis for screening out the patients suitable for TACE.Among the existing prognostic evaluation models for primary liver cancer,6&12 criteria have a better predictive capability than the other models.