解剖性肝切除治疗肝细胞癌的长期结果和预后影响因素分析：附90例报告

Long-term results and prognostic factors after anatomical hepatectomy for hepatocellular carcinoma： a report of 90 patients

目的探讨解剖性肝切除治疗肝细胞癌的安全性、长期结果以及预后影响因素。方法从2003年1月至2010年i月对90例可手术切除的肝细胞癌实施解剖性肝切除术，肿瘤大小：≤5cm38例，〉5cm52例；肿瘤数目：单发病灶57例，2个以上多发瘤灶33例。肝癌合并肝硬化45例（50．0％）；合并脉管癌栓34例（37．78％）。肝功能分级：Child—PughA级64例，B级26例。术中统计手术时间、出血量以及输血量；术后观察并发症、肝功能。采用Kaplan-Meier法计算无瘤生存率和累积生存率。肿瘤复发与相关单因素分析采用log—rank检验。通过Cox回归进行多因素分析确定影响患者无瘤生存期和总生存期的独立因素。结果全组无死亡。术后并发症发生率为31．1％（28／90）。术后复发率为51．1％（46／90），术后1、3、5年无瘤生存率分别为92．2％、67．3％和49．7％。切缘阳性（相对危险度为13．83，95％可信区间为4．56±41．96）和子灶（相对危险度为3．09，95％可信区间为1．60～5．98）为影响预后的独立因素。术后1、3、5年总的累积生存率分别为94．4％、80．0％和60．0％。Cox回归分析显示切缘阳性（相对危险度为19．22，95％可信区间为5．85～63．17）和TNM分期（相对危险度为2．013，95％可信区间为1．28～3．17）为影响预后的独立因素。结论解剖性肝切除是治疗肝细胞癌安全有效的术式。术后复发主要与肿瘤切缘阳性和TNM分期有关。在保证切缘阴性方面，解剖性肝切除具有明显优势。

Objective To investigate the safety and long-term therapeutic results of anatomical hepatectomy for hepatocellular carcinoma （HCC）. Methods 90 patients underwent anatomical hepatectomy from January, 2003 to January, 2010. The tumor size was 45 cm in 38 patients, and ~5 cm in 52 patients. The tumor number was a single lesion in 58 patients, and multiple lesions in 32 patients. Cirrhosis was present in 46 patients （55.42%）, cancer embolus was present in 34 patients （37.78%）. There were 64 patients in Child-Pugh A and 26 patients in B. The operating time, blood loss and blood transfusion were recorded and analyzed. Complications and liver function were moni- tored after surgery. The Kaplan-Meier method was used to calculate the survival rates. Log-rank test was used to analyze factors associating with postoperative recurrence. Independent factors influencing tumor-free survival and overall survival were analyzed by Cox-model logistic regression. Result There was no perioperative death. The incidence of complications was 31.1% （28/90）. The recurrence rate was 51.1% （46/90）. The 1-, 3-, 5-year tumor-free survivals were 92.2%, 67.3% and 49.7%, re- spectively. Positive resection margin and satellite nodule were independent factors for recurrence （RR 19. 22, 95% confidence interval 5.85~63.17）. The 1-, 3-, 5-year overall survivals were 94.4%, 80.0% and 60.0%, respectively. Positive resection margin and TNM were independent factors for overall survival （RR 2. 013, 95% confidence interval 1.28±3.17）. Conclusions Anatomical hepatectomy was a safe and efficacious procedure to treat HCC. Positive resection margin and TNM were independent factors associated with overall survival. Anatomical hepatectomy had the advantages in ensuring a lower rate of negative resection margin.