567例不同病理类型的原发性肝癌肝切除术后预后分析

Prognosis of primary liver cancer with different pathological types after hepatectomy： a report of 567 cases

目的探讨不同病理类型的原发性肝癌患者行肝切除术后的生存状况及临床病理因素对生存的影响，为疾病的预后研究提供参考。方法回顾性分析1997年1月至2008年12月青岛大学医学院附属医院收治的567例原发性肝癌肝切除术患者的临床资料。按照病理类型将患者分为肝细胞癌、胆管细胞癌、混合型肝癌。分析3种病理类型的肝癌患者的生存情况及影响其预后的危险因素。多组比较采用方差分析，计数资料采用x^2检验，计量资料采用t检验，生存分析采用Kaplan—Meier法绘制患者生存曲线，生存情况比较采用Logrank检验，单因素分析和COX回归模型分析影响患者预后的临床病理因素。结果567例患者中经病理检查证实为肝细胞癌者占92．9％（527／567），胆管细胞癌者占4．6％（26／567），混合型肝癌者占2．5％（14／567）。肝细胞癌患者中位累积生存时间为48个月，明显长于胆管细胞癌患者的19个月和混合型肝癌患者的14个月，肝细胞癌患者累积生存情况明显优于胆管细胞癌和混合型肝癌患者（Log—rank值为4．354，8．847，P〈0．05）；肝细胞癌患者中位无瘤生存时间为26个月，明显长于胆管细胞癌患者的9个月和混合型肝癌患者的9个月，肝细胞癌患者无瘤生存情况明显优于胆管癌细胞癌和混合型肝癌患者（Log—rank值为6．479，7．708，P〈0．05）。肝细胞癌患者的1年肿瘤复发率为28．8％（152／527），显著低于胆管细胞癌患者的57．7％（15／26）和混合型肝癌患者的9／14（F=17．046，P〈0．05）。胆管细胞癌患者未发现血管癌栓，但区域淋巴结转移率为19．2％（5／26），显著高于肝细胞癌患者的2．8％（15／527），两者比较，差异有统计学意义（x。=19．082，P〈0．05）。AFP、TNM分期、肿瘤直径、病灶数目、肿瘤侵犯肝被膜、卫星灶、区域淋巴结转移等是影响原发性肝癌患者肝切除术后总体生存的因素（x2=8．648，118．786，59．548，7．639，13．200，43．842，15．540，P〈0．05）；血管癌栓和Child—Pugh分级是影响肝细胞癌和混合型肝癌患者总体生存的因素（x^2=70．446，6．230，P〈0．05）。肝癌患者TNM分期、肿瘤直径、卫星灶、血管癌栓是影响3种病理类型肝癌肝切除术后预后的独立危险因素（艘=1．420，1．050，1．513，1．899，P〈0．05）；TNM分期、肿瘤直径和血管癌栓是影响肝细胞癌患者预后的独立危险因素（RR=1．432，1．888，1．052，P〈0．05）；TNM分期和肿瘤直径是影响胆管细胞癌患者预后的独立危险因素（RR=1．473，1．503，P〈0．05）。结论虽然胆管细胞癌和混合型肝癌两种病理类型仅占原发性肝癌的少数，但与肝细胞癌患者比较，肝切除术后肿瘤早期复发率高，患者生存率低。

Objective To investigate the prognosis of patients with primary liver cancer in different patho- logical types after hepatectomy, and to analyze the effects of clinieopathological factors on the survival. Methods The clinical data of 567 patients with primary liver cancer who received hepatectomy at the Affiliated Hospital of Qingdao University from January 1997 to December 2008 were retrospectively analyzed. All patients were divided into hepatocellular carcinoma （HCC） group, cholangiocarcinoma （CC） group and combined hepatocellular carci- noma and cholangiocarcinoma （cHCC-CC） group. The survival and risk factors of the patients were analyzed. All data were analyzed by using the chi-square test, t test, analysis of variance. The survival curve was drawn by the Kaplan-Meier method and the survival of the 3 groups was compared by the Log-rank test. The risk factors were analyzed by the one-way analysis of variance and COX regression model. Results The results of pathological examination confirmed that 92.9% （527/567） patients were with HCC, 4.6% （26/576） with CC and 2.5% （14/567） with cHCC-CC. The median cumulative survival time of patients with HCC was 48 months, which was significantly longer than 19 months of patients with CC and 14 months of patients with cHCC-CC （ Log-rank value = 4. 354, 8. 847, P 〈 0. 05 ）. The median tumor-free survival time of patients with HCC was 26 months, which was significantly longer than 9 months of patients with CC and 9 months of patients with cHCC-CC （ Log-rank value = 6. 479, 7. 708, P 〈 0.05）. The tumor recurrence rate within 1 year of patients with HCC was 28.8% （152/527） , which was significantly lower than 57.7% （15/26） of patients with CC or 9/14 of patients with cHCC-CC （ F = 17. 046, P 〈 0.05 ）. No vascular thrombosis was detected in patients with CC, but the regional lymph node metastasis rate was 19.2% （ 5/26 ）, which was significantly higher than 2.8% （ 15/527 ） of patients with HCC （ X2 = 19.082, P 〈 0.05 ）. Level of alpha-fetoprotein, TNM staging, tumor diameter, multiple loci, liver capsule invasion, satellite loci and lymph node metastasis were risk factors for the survivals of patients with primary liver cancer after hepatectomy （X2 = 8. 648, 118. 786, 59. 548, 7. 639, 13. 200, 43. 842, 15. 540, P 〈 0.05）. Vascular tumor thrombosis and Child-Pugh classification were the risk factors for the survivals of patients with HCC or cHCC-CC （X2 = 70. 446, 6. 230, P 〈 0.05）. TNM staging, tumor diameter, satellite loci and vascular tumor tbrombusis were the independent risk factors for the survivals of patients wit^primary liver cancer （RR = 1. 420, 1. 050, 1. 513, 1. 899, P 〈 0.05 ） ; TNM staging, tumor diameter and vascular tumor thrombosis were the independent risk factors for the survivals of patients with HCC （RR = 1. 432, 1. 888, 1. 052, P 〈 0.05）. TNM staging and tumor diameter were the independent risk factors for the survivals patients with CC （ RR = 1. 473, 1. 503, P 〈 0.05 ）. Conclusion Although CC and cHCC-CC take small proportion in the primary liver cancer, the tumor recurrence rate is higher and the survival rate is lower when compared with patients with HCC.