不同中国肝癌分期肝癌根治性切除术后的临床效果及预后因素分析

目的探讨不同中国肝癌分期(CNLC)肝癌接受根治性切除术后的临床效果及长期生存的预后因素。方法回顾性分析2010年1月至2019年12月南京医科大学第一附属医院肝胆中心单一治疗组收治的行肝癌根治术的549例肝细胞癌(HCC)患者的临床病理学资料。男性462例(84.2%),女性87例(15.8%);中位年龄57岁(范围:21~84岁)。观察患者的术前变量、术中及术后情况、术后病理学检查结果等。采用门诊与电话相结合的方式进行随访。采用寿命表法进行生存率的估计,采用Kaplan-Meier法绘制总体生存和无瘤生存曲线,采用Log-rank检验比较不同组别生存过程的差异,采用多因素Cox回归模型分析影响预后的主要因素。结果 549例HCC患者中,CNLC Ⅰa期200例(36.4%),CNLC Ⅰb 期148例(27.0%),CNLC Ⅱa期49例(8.9%),CNLC Ⅱb期32 例(5.8%),CNLC Ⅲa期101例(18.4%),CNLC Ⅲb期19例(3.5%)。患者1、3、5、10年总体生存率分别为83.8%、69.0%、54.2%、37.7%,1、3、5年无瘤生存率分别为61.0%、44.2%、36.0%。CNLC Ⅰa期患者的1、3、5年总体生存率和无瘤生存率分别为97.3%、90.6%、80.5%和83.9%、65.0%、54.0%;CNLC Ⅰb期患者的1、3、5年总体生存率和无瘤生存率分别为87.9%、71.0%、47.7%和58.4%、42.3%、33.4%;CNLC Ⅱa和Ⅱb期患者的5年总体生存率(Ⅱa期:37.2%,Ⅱb期:44.3%)与CNLC Ⅰb期类似。CNLC Ⅲb期患者 1、3、5年总体生存率和无瘤生存率分别为35.3%、13.2%、0和23.5%、0、0。单因素分析结果显示,术前合并症状、术前甲胎蛋白水平、术前总蛋白水平、术前AST水平、术前总胆红素水平、术中出血量、术中或术后输血、术后并发症、肿瘤最大径和数目、微血管侵犯、大血管侵犯、肿瘤分化程度是HCC患者长期生存(≥5年)的预后因素(P值均<0.05)。多因素分析结果显示,术前AST水平、术中出血量、肿瘤数目、肿瘤最大径、大血管侵犯和肿瘤分级是HCC患者长期生存的独立预后因素(P值均<0.05)。结论不同CNLC的HCC患者具有不同的复发模式及预后。经过严格术前评估的CNLC Ⅱa~Ⅲb期HCC患者可从外科根治切除术中获得生存获益。术前AST水平、术中出血量、肿瘤数目、肿瘤最大径、大血管侵犯和肿瘤分化程度是影响HCC患者长期生存的独立预后因素。

Clinical efficacy and prognostic factors analysis following curative hepatectomy for hepatocellular carcinoma patients with different China Liver Cancer Staging

Objective To examine clinical efficacy and prognostic factors of hepatocellular carcinoma(HCC)patients with different China Liver Cancer Staging(CNLC)after hepatectomy.Methods From January 2010 to December,2019,549 patients underwent surgical resection and pathologically proven HCC were retrospectively reviewed in the First Affiliated Hospital of Nanjing Medical University.There were 462 males(84.2%)and 87 females(15.8%);the median age was 57 years(range:21-84 years).Preoperative parameters,intraoperative and postoperative conditions,and postoperative pathological examination were observed.Survival analysis was performed by Kaplan-Meier method and the Log-rank test.Factors associated with disease-free survival(DFS)and overall survival(OS)of HCC patients were identified using univariate and multivariate Cox proportional hazards regression models.Results Among the 549 patients underedwent liver resection,200 patients(36.4%)belonged to CNLCⅠa,whiles 148 patients(27.0%)belonged to CNLCⅠb.Furthermore,there were 49 patients(8.9%)with CNLCⅡa,32 patients(5.8%)with CNLCⅡb,101 patients(18.4%)with CNLCⅢa and 19 patients(3.5%)with CNLCⅢb.The 1-,3-,5-,10-year OS for the entire cohort was 83.8%,69.0%,54.2%,37.7%,respectively,while 1-,3-,5-year DFS was 61.0%,44.2%,36.0%,respectively.The 1-,3-,5-year OS and DFS for CNLCⅠa were 97.3%,90.6%,80.5%and 83.9%,65.0%,54.0%,respectively;The 1-,3-,5-years OS and DFS for CNLCⅠb were 87.9%,71.0%,47.7%,and 58.4%,42.3%,33.4%,respectively.The 5-year OS for CNLCⅡa(37.2%)andⅡb(44.3%)were similar to CNLCⅠb.The 1-,3-,5-year OS and DFS for CNLCⅢb were 35.3%,13.2%,0 and 23.5%,0 and 0,respectively.Univariate analysis showed that preoperative symptoms,AFP level,total protein level,AST level,total bilirubin level,intraoperative blood loss,intraoperative or postoperative blood transfusion,postoperative complications,tumor number and size,microvascular invasion,macrovascular invasion and tumor differentiation were prognostic factors for long-term survival(≥5 years)(all P<0.05).The multivariate analysis suggested that AST level,intraoperative blood loss,tumor number and size,macrovascular invasion and tumor differentiation were the independent prognostic factors of long-term OS(all P<0.05).Conclusions HCC patients with different stages of CNLC have different recurrence patterns and prognosis.After strict preoperative evaluation,patients with CNLCⅡa-Ⅲb can also benefit from radical resection.AST level,intraoperative blood loss,tumor number,tumor size,macrovascular invasion and tumor differentiation were independent factors that affect long-term survival.This will provide an important basis for the choice of treatment and the evaluation of surgical prognosis for patients with HCC.