早期肝细胞肝癌患者的手术治疗方法选择

Selection of surgical procedure in the treatment of early hepatocellular carcinoma

目的探讨治疗早期肝细胞肝癌（肝癌）患者的手术方法。方法回顾性分析2002年1月至2009年12月在西安交通大学医学院第一附属医院行肝切除或肝移植，经病理学证实为肝癌的53例符合米兰标准患者的临床资料。按照治疗方法将患者分为肝切除组和肝移植组。肝切除组31例，其中男22例，女9例；年龄（54±10）岁。肝移植组22例，其中男19例，女3例；年龄（49±9）岁。患者均签署知情同意书，符合医学伦理学规定。患者一般临床资料比较采用t检验、秩和检验和矿检验。根据随访结果绘制Kaplan—Meier生存曲线，采用Log—rank检验法分析患者累积生存率和无瘤生存率。利用Cox比例风险回归模型对两组患者进行独立危险因素的预后分析。结果肝切除组与肝移植组患者的年龄、性别、乙型肝炎表面抗原（HBsAg）阳性率、丙型肝炎病毒抗体（抗-HCV）阳性率、甲胎蛋白（AFP）水平、肝功能Child—Pugh分级、肿瘤数目、肿瘤大小、肝被膜侵犯及肿瘤Edmonson分级比较差异无统计学意义（均为P〉0．05）。所有患者均获得随访，随访时间6～91个月，平均随访时间为35个月。肝切除组术后的1、2、3年累积生存率分别为87％、80％、71％，肝移植组分别为86％、77％、68％，两组累积生存率比较差异无统计学意义（X2=0．739，19〉0．05）。肝切除组术后1、2、3年无瘤生存率分别为84％、77％、74％，肝移植组分别为77％、68％、59％，两组无瘤生存率比较差异亦无统计学意义（t2=0．826，P〉O．05）。对于肝功能Child—Pugh分级A级的患者，肝切除组与肝移植组术后的累积生存率和无瘤生存率比较差异无统计学意义（X2=2．562，2．676；P〉O．05）。对于肝功能Child—Pugh分级B级患者，肝切除组与肝移植组术后累积生存率和无瘤生存率比较差异亦无统计学意义（X2=0．006，0．012；P〉0．05）。手术方式及肿瘤Edmonson分级与患者的预后显著相关（RR=0．291，5．878；P=0．025，0．020），选择肝切除及肿瘤分化程度较高的患者，其预后较好。结论对于符合米兰标准的肝功能Child—Pugh分级A级和B级的肝癌患者，应以肝切除作为首选治疗方法；肝癌患者术后预后与肿瘤组织学分级有关，肿瘤分化程度较高的患者，其预后较好。

Objective To discuss the selection of surgical procedure for early hepatocellular carcinoma （HCC） patients by comparing the efficacy of liver resection and transplantation and analyzing the independent risk factors of patients＂ survival. Methods Clinical data of 53 HCC patients received hepatic resection or liver transplantation in the First Affiliated Hospital, School of Medicine, Xi＇an Jiaotong University from January 2002 to December 2009 were analyzed retrospectively. The patients were pathologically confirmed as HCC and met with the Milan criteria. The patients were divided into the liver resection group and liver transplantation group. There were 31 cases in the liver resection group （22 males and 9 females） with the age of （54＋10） years old. There were 22 cases in the transplantation group （19 males and 3 females） with the age of （49＋9） years old. The informed consents of all patients were obtained and the ethical committee approval was received. The general clinical data of the patients were compared by t test, rank sum test, and chi-sqnare test. And the prognosis analysis of patients in the 2 groups were conducted using Cox multiple regression model. Results There were no significant differences in the patients＂ age, gender, positive rate of hepatitis B surface antigen （HBsAg） and hepatitis C virus antibody, alpha-fetoprotein （AFP）, Child-Pugh grading, tumor numbers, size, liver capsule infiltration and tumor Edmonson grading between 2 groups （all in P〉O.05）. All the patients were followed up for 6-91 months with an average of 35 months. The 1-, 2-, 3-year cumulative survival rates were 87%, 80%, 71% in the liver resection group and were 86%, 77%, 68% in the liver transplantation group respectively. There was no significant difference in the cumulative survival rate beween 2 groups （X2=0.739, P〉0.05）. The 1-, 2-, 3-year disease free survival rates were 84%, 77%, 74% in the liver resection group and were 77%, 68%, 59% in the liver transplantation group. There was no significant difference in the disease free survival rate between 2 groups （X2=0.826, P〉0.05）. For the Child-Pugh grade A patients, no significant differences were observed in the comparison of cumulative survival rates and disease free survival rates between 2 groups （X2=2.562, 2.676; P〉0.05）, which was the same as the grade B patients 0（2=0.006, 0.012; P〉O.05）. The surgical procedure and tumor Edmonson grading were significantly related with the patients＂ prognosis（RR= 0.291, 5.878; P=0.025, 0.020）. The patients who received liver resection and with high degree of tumor differentiation had better prognosis. Conclusions For the HCC patients within Milan Criteria and with liver function of Child-Pugh grade A or B, liver resection should be the preferred treatment. The patients＂ prognosis after the operation is related with tumor differentiation. The patients with high degree of tumor differentiation have better prognosis.