肝细胞癌病理学微侵袭的影响因素对放疗靶区确定的潜在价值

The impact factors for pathologic micro-invasion of hepatocellular carcinoma： possible application for CTV definition

目的通过病理切片观察肝细胞癌镜下外侵特点，提供准确的病灶浸润范围，以指导临床医生确定放疗靶区范围。方法搜集4年间149例肝细胞癌手术切除的病理标本及其相关临床资料，包括肿瘤最大直径、包膜情况、边界情况、门脉癌栓、TNM临床分期、Edmondson-Steiner分级、血清中AFP值、末梢血血小板计数、肝硬化程度。肿瘤切缘必须〉1cm，术前影像学检查及术中探查均未发现原发肿瘤周边子灶。通过常规病理切片在显微镜下确定肝癌微侵袭灶距离。结果肿瘤微侵袭灶距原发灶距离最远为4mm，范围0．5～4．0mm，平均（1．64±0．09）mm。有微侵袭灶者较无侵袭灶者易出现复发，其复发率分别为44％（35／79）和29％（20／70）（P=0．047）。肿瘤最大直径、包膜情况、边界情况、门脉癌栓、TNM临床分期、Edmondson-Steiner分级、血清中AFP值、末梢血血小板计数、肝硬化程度与微侵袭灶有关（P值均〈0．05）。通过对肿瘤最大直径、肿瘤包膜、门脉癌栓、血清中AFP值、末梢血血小板计数5项简单临床指标评分，0～2分者自包膜外扩2mm即能达到97％的准确性。〉2分者准确性仅83％。结论肝细胞癌的微侵袭灶外侵距离与肿瘤最大直径、肿瘤包膜、门脉癌栓、血清中AFP值、末梢血血小板计数有关，通过5项简单临床指标评分可初步判断外侵范围。

Objective To evaluate the microscopic characteristics of hepatocellular carcinoma （HCC） invasion,and to provide the reference for GTV-to-CTV expansion. Methods From January 2002 to January 2006,149 HCC patients treated by surgical resection were included. The pathologic slices and clinical data were reviewed, including the tumor size, capsule status, tumor edge, portal vein invasion, TNM stage,histology grade, serum alpha-fetoprotein（ AFP）, platelet count and the degree of liver cirrhosis. The distance between the tumor capsule and the invasion was measured by 2 senior pathologists. Results Of the 149 patients evaluated,79（53.0% ） patients presented micro-invasion ranged between 0.5-4.0 mm. The recurrence rate was higher in patients with micro-invasion than those without （44% vs 29% , P = 0.047 ）. The invasion extent was positively relative to the tumor size, capsule status, tumor edge, portal vein invasion, TNM stage,histology grade and AFP,while negatively relative to the platelet count. A score system was established according to five predictors of tumor size, capsule status, portal vein invasion, AFP and platelet count. The invasion distance below 2 mm was in 96.6% patients who had≤2 points and only 83.3% for those with 〉 2 points. Conclusions For HCC patients, the invasion extent is relative to the tumor size,capsule status,portal vein invasion, AFP and platelet count. These 5 predictors could be potentially used as a score system for GTV-to-CTV expansion.