肝细胞癌手术后应用不同分期评估预后的临床研究

Evaluation of the different staging systems as a predictor of prognosis for hepatocellular carcinoma patients after hepatic resection

目的评估不同肝细胞癌（hepatocellular carcinoma,HCC）分期对HCC肝切除术后的预后判断能力。方法1991年1月至2002年6月西南医院实施根治性肝切除,且具有完整随访资料和临床资料的234例HCC,TNM分期（第6版）与Okuda分期、意大利肝癌工作组（CLIP）评分系统以及香港中文大学预后指数（CUPI）进行比较,利用病例构成比、生存曲线、受试者工作特征曲线（ROC曲线）下面积分别比较各预后评估系统的病例分层能力、术后长时间预后判断能力和预后结果判别能力。结果病例构成比：TNM分期Ⅰ、Ⅱ、Ⅲ期分别为31.6%、29.5%和38.9%;OkudaⅠ、Ⅱ期分别为82.9％和17.1％;CLIP评分系统0、1、2和3分以上分别为37.2%、48.3%、12.4%和2.2%;CUPIⅠ、Ⅱ、Ⅲ级分别为78.6%、20.1%和1.3%。生存率曲线比较：TNM分期Ⅰ期在术后60个月,仍具有明显的预后判断能力,Ⅱ期和Ⅲ期在术后60个月预后接近;Okuda分期和CLIP评分系统术后60个月生存曲线接近;CUPIⅠ级和Ⅱ级在术后60个月后仍然具有良好的预后判断能力。ROC曲线面积比较：TNM分期、Okuda分期、CLIP和CUPI ROC曲线下面积分别为0.683、0.595、0.620和0.596,TNM分期和CLIP评分系统比较存在显著性差异（P=0.0384）,CLIP评分系统与CUPI、Okuda分期比较差异无统计学意义（P=0.4681和P=0.3859）。结论对于根治性HCC病例,第6版TNM分期较Okuda分期、CLIP评分系统及CUPI更具有预后判断价值。

Objective To evaluate the 6th edition of TNM staging system for hepatocellular carcinoma in 234 patients after hepatic resection. Methods A retrospective study was carried out in 234 patients after hepatic resection during a period from January 1991 to June 2002. We evaluate the prognostic value of the 6th edition of TNM staging, Okuda staging system, Cancer of the Liver Italian Program （CLIP） scoring system, and Chinese University Prognostic Index （CUPI）. The distribution, survival curve and area under a receiver operating characteristic （ ROC ） curve for each stage and substages were used to compare survival rates observed in our patients with surgical operation-related factors. Results Based on TNM staging, 31.6% patients were on Stage Ⅰ disease, 29. 5% patients on Stage Ⅱ disease, and 38.9% patients on Stage Ⅲ disease; Based on Okuda staging, 82.9% on Stage Ⅰ disease, and 17. 1% on Stage Ⅱ disease; By CLIP scoring system, 37. 2% ,48.3%, 12.4% and 2.2% on score 0, 1,2 and 3-4, respectively; By CUPI, 78. 6% , 20. 1% and 1.3% for low, intermediate and high risk group, respectively. The Kaplan-Meier survival curve showed that TNM staging （especially for Stage Ⅰ ） and CUPI could predict long-term survival （60-month） effectively, however, Okuda staging and CLIP scoring lost their prognostic value at 60-month after hepatic resection. The area under the curve （AUC） of TNM, Okuda, CLIP and CUPI was 0. 683, 0. 595, 0. 620 and 0. 596, respectively, as a predictor of clinical outcome at 26. 35-month （median survival time ）. Condusion The 6th edition of TNM staging has more significant prognostic value than Okuda staging system, CLIP scoring system and CUPI in HCC patients undergoing hepatic resection.