肝硬化肝癌患者手术切除预后影响因素的回顾性研究

目的 探讨合并肝硬化的不同大小肝癌患者临床资料特点及肝切除术近远期预后的影响因素.方法 回顾性分析第三军医大学西南医院2008-2012年期间因肝癌而接受肝脏切除手术且具有肝硬化的连续患者资料共703例.收集患者临床病理资料并进行随访.对可能影响近、远期预后的因素分别进行Logistic及Cox回归分析.结果 703例患者中,男性638例,女性65例.其中,肿瘤最大直径＜5 cm的患者(小肝癌组,ST组)280例(39.8％),肿瘤最大直径≥5 cm的患者(大肝癌组,LT组)423例(60.2％).与ST组患者比较,LT组患者术前甲胎蛋白、天门冬氨酸氨基转移酶(AST)及脉管癌栓发生率较高,但白蛋白及血小板较低.术中资料表明LT组患者复杂手术比例、术中失血量、肝门阻断时间及手术时间都较高.而LT组患者术后并发症的总发生率也较高(35.0％vs27.1％,P=0.029).多因素分析显示,在ST组中,复杂手术(OR:2.755,95％CI:1.196～6.344,P=0.017)是独立的危险因素,而白蛋白水平低于35g/L(OR:4.049,95％CI:2.105 ～ 7.752,P＜0.01)与手术时间＞240 min(OR:3.044,95％CI:1.912 ～4.847,P＜0.01)是LT组独立的危险因素.远期预后分析显示:LT组患者无瘤生存时间(progression-free survival,PFS)和总生存时间(overall-survival,OS)均比ST组短(P＜0.01).多因素分析显示,在ST组中,癌栓是影响PFS的独立危险因素;而Child-Pugh B级、癌栓和复杂手术是影响OS的独立危险因素.在LT组中,癌栓和手术时间＞240 min均为影响PFS的独立危险因素;而AST ＞40 U/L和癌栓是影响OS的独立危险因素.结论 直径＜5 cm的小肝癌较之直径≥5 cm的大肝癌患者有着更高的近、远期生存率.而选择无癌栓的大肝癌病例,改善术前白蛋白、转氨酶水平,提高手术熟练度及合理使用手术器械如射频消融辅助(radiofrequency ablation assist,RFA)]以缩短手术时间,可以降低术后并发症并改善大肝癌手术治疗的预后.

Prognosis of hepatocellular carcinoma patients with liver cirrhosis after hepatectomy: a retrospective study

Objective To investigate the clinical characteristics of hepatocellular carcinoma (HCC) patients with liver cirrhosis and the prognostic factors influencing the short-and long-term outcomes after hepatectomy.Methods We retrospectively analyzed 703 HCC patients with liver cirrhosis who underwent hepatectomy from January 2008 to December 2012 in our hospital.Among the 703 patients,638 were males (90.8％) and 65 were females (9.2％).The patients were divided into 2 groups based on the tumor size:small tumor (ST) group (diameter ＜5 cm,n =280,39.8％) and large tumor (LT) group (diameter ≥5 cm,n =423,60.2％).The potential prognostic factors affecting the short-and long-term outcomes were analyzed using univariate and multivariate logistic and Cox regression analyses.Results Compared with the ST group,the LT group had higher alpha-fetoprotein (AFP) and aspartate aminotransferase (AST) levels with increased incidence of tumor embolization,but lower albumin and platelet levels pre-operatiuely.Intraoperative data showed that the LT group had larger proportion of patient with complex surgery,more intraoperative blood loss,longer hepatic hilar obstruction and operation time.Moreover,the overall incidence of postoperative complications was significantly higher in the LT group than the ST group (35.0％ vs 27.1％,P =0.029).The multivariate logistic regression analysis showed that the surgery complexity (OR =2.755,95％ CI:1.196 ～ 6.344,P =0.017) was an independent risk factor for the development of postoperative complications in the ST group,while albumin level ＜ 35 g/L(OR =4.049,95％ CI:2.105 ～ 7.752,P ＜ 0.01) and operation time ＞240 min (OR =3.044,95％ CI:1.912 ～ 4.847,P ＜ 0.01) were the factors for the LT group.Postoperative long-term outcome showed that progression-free survival (PFS) and overall survival (OS) were shorter in the LT group than the ST group (P =0.001).The multivariate Cox regression analysis demonstrated that tumor embolization was an independent risk factor influencing PFS in both groups,and operation time ＞ 240 min was exclusive in the LT group.Additionally,the independent risk factors influencing OS in the ST group were Child-Pugh class B,tumor embolization and operation time ＞ 240 min,whereas in the LT groups the factors were AST ＞ 40 IU/l and tumor embolization.Gonclusion HCC patients with tumors ＜ 5 cm have better short-and long-term outcomes than those with tumors ≥ 5 cm.For LT group patients without tumor embolization,increasing preoperative albumin and transaminase levels,advancing surgical proficiency and rational use of instruments (such as radiofrequency ablation assist,RFA) to shorten the operation time,can not only reduce postoperative complications,but also improve the long-term outcomes.