原发性肝癌区域淋巴结转移的临床病理特点及预后分析

Clinicopathological features and prognosis of regional lymph node metastasis in patients with the hepatocellular carcinoma

目的探讨原发性肝细胞癌(HCC)区域淋巴结转移的临床特点,及其对肝癌术后预后的影响因素分析。方法回顾性分析2001-01-20—2015-12-20在菏泽市立医院因HCC行肝切除的232例患者临床资料和随访结果。根据区域淋巴结转移情况分为转移组(17例)和非转移组(215例)。单因素分析2组间甲胎蛋白水平等指标差异性,二分类Logistic回归多因素分析与区域淋巴结转移有关的独立危险因素,Kaplan-Meier法进行生存率曲线描述。结果单因素分析显示,甲胎蛋白水平、最大肿瘤直径、组织学分化程度、肿瘤破裂、肿瘤包膜情况、卫星病灶、脉管癌栓、TNM分期和区域淋巴结转移是影响HCC患者术后生存的危险因素。Cox多因素分析显示,肿瘤包膜缺如(HR=0.539,95%CI为0.355~0.820,P=0.004)、合并卫星灶(HR=1.997,95%CI为1.189~3.355,P=0.009)和区域淋巴结转移阳性(HR=2.365,95%CI为1.158~4.832,P=0.018)是影响HCC患者术后生存的独立危险因素。2组患者比较,单因素分析显示最大瘤径>5 cm、组织学类型为低分化和肿瘤包膜缺如与区域淋巴结转移有相关性,χ^(2)值分别为11.714、13.941和8.057,P值分别为0.001、<0.001和0.005。二分类Logistic回归多因素分析结果显示,组织学为低分化(OR=6.085,95%CI为0.702~4.043,P=0.003)和最大瘤径>5 cm(OR=11.572,95%CI为1.097~19.326,P=0.020)是影响淋巴结转移独立危险因素。转移组1、3和5年总体生存率(OS)分别为70.6%、41.2%和23.5%,非转移组分别为94.0%、72.5%和57.4%,P<0.001;在随访期内,转移组复发率为82.4%(14/17),非转移组复发率为56.3%(121/215),χ^(2)=8.745,P=0.003。17例转移组患者中11例伴第8a组淋巴结转移。结论术中应将第8a组淋巴结作为肝门区淋巴结探查的“前哨淋巴结”进行处理。区域淋巴结转移是影响预后的独立危险因素,行淋巴结清除配合术后多学科综合治疗,一方面可为术后肿瘤分期提供准确依据,另一方面为患者增加预后生存获益。

Objective To discuss the clinical characteristics and analyse the prognostic factors with regional lymph node metastasis in patients with HCC accepted hepatectomy.Methods The clinicopathological and follow-up data of 232 HCC patients(metastasis group n=17;no-metastasis group n=215)underwent hepatectomy in the He-ze municiple hospital were included from January 20,2001to December 20,2015.Univariate analysis was used to compare indicators’differences between the two groups,including alpha-fetoprotein and others.Logistic regression Multivariate analysis was used to analysis the independent risk factors associated with regional lymph node metastasis.Kaplan-meier method was used to describe the survival rate curve.Results Univariate analysis showed that alpha fetoprotein level,tumor size,histological differentiation,tumor rupture,tumor capsule,satellite lesion,vascular tumor thrombus,TNM stage,regional lymph node metastasis were important factors for postoperative survival of 232 HCC patients.By multivariate analysis,the absence of tumor encapsulation(HR=0.539,95%CI:0.355-0.820,P=0.004),satellite lesions(HR=1.997,95%CI:1.189-3.355,P=0.009)and positive regional lymph node metastasis(HR=2.365,95%CI:1.158-4.832,P=0.018)were independent risk factors for postoperative survival of patients with HCC.Compared with No-metastasis group,the patients with Max-diameter>5cm(χ;=11.714,P=0.001),poorly differentiation(χ;=13.941,P<0.001)and the absence of tumor encapsulation(χ;=8.057,P=0.005)in the metastasis group increased significantly.Logistic regression analysis showed that poorly differentiation(OR=6.085,95%CI:0.702-4.043,P=0.003)and Max-diameter>5cm(OR=11.572,95%CI:1.097-19.326,P=0.020)were independent risk factors for lymph node metastasis.The overall survival(OS)rate after 1,3,5years was 70.6%,41.2%,23.5%in the metastasis group and 94.0%,72.5%,57.4%in the No-metastasis group(Log-rank test:P<0.001).During the follow-up period,the recurrence rate of metastasis group was 82.4%(14/17)and no-metastasis group was 56.3%(121/215,P=0.003).Among the 17patients in metastasis group,11patients had lymph node metastasis in No.8agroup.Conclusions The No.8group of lymph nodes should be treated as"sentinel lymph nodes"for the exploration of hilar lymph nodes.Regional lymph node metastasis is an independent risk factor for prognosis.Radical resection on HCC patients with regional lymph node metastasis combined with MDT can provide accurate basis for postoperative tumor staging and increase the survival benefits of patients.