无肿瘤包膜的肝细胞癌临床病理特征及术后预后分析

Clinicopathologic Features of Hepatocellular Carcinoma without Fibrous Capsule and the Postoperative Prognostic Analysis

目的 阐明无肿瘤包膜肝癌的临床病理特征及无肿瘤包膜究竟在多大程度上影响肝癌切除术后无瘤生存及总生存,分析影响无肿瘤包膜肝癌的预后因素.方法 回顾性分析2001年至2009年间手术切除的210例肝癌,t检验或卡方检验比较无包膜与有包膜的肝癌临床病理特点,Kaplan-Meier生存函数分析无瘤生存及总生存,log-rank检验比较生存曲线间的差异,单因素分析影响无肿瘤包膜肝癌无瘤生存及总生存率的因素,COX比例风险回归模型分析与无包膜肝癌预后相关的危险因素.结果 无肿瘤包膜的肝癌在性别、年龄、肝硬化、Child分级、HBsAg、甲胎蛋白、门静脉高压、谷草转氨酶、谷丙转氨酶、白蛋白、直接胆红素、血小板计数上与有包膜的肝癌差异均无统计学意义（均P〉0.05）,但无肿瘤包膜肝癌总胆红素值显著高于有包膜的肝癌（P=0.005）.无肿瘤包膜肝癌血管侵犯、中低分化的比例显著高于有包膜肝癌;无肿瘤包膜肝癌1、3及5年无瘤生存率分别为62.6%、34.2%及30.8%,显著低于有包膜组的91.0%、78.0%及64.9%（均P〈0.001）,无肿瘤包膜肝癌1、3及5年总生存率分别为82.4%、53.6%及44.2%,显著低于有包膜组的97.3%、88.9%及77.3%（均P〈0.001）.影响无肿瘤包膜肝癌无瘤生存率的独立危险因子为中低分化程度（HR,3.181;95%CI,1.428～7.082,P=0.003）、血管侵犯（HR,4.164;95%CI,2.063～8.405,P＜0.001）;影响无肿瘤包膜肝癌总生存率的独立危险因子为Child B级（HR,3.92;95%CI,1.176～13.066,P=0.026）、中低分化程度（HR,14.875;95%CI,2.039～108.496,P〈0.001）、血管侵犯（HR,7.112;95%CI,3.60～14.05,P＜0.001）.结论 无肿瘤包膜肝癌比有包膜的肝癌更易发生血管侵犯,分化程度更低,术后复发率更高,总生存率更差.

Objective To elucidate the clinicopathologic features of hepatocellular carcinoma without fibrous capsule,and analyze the extent to what the absence of capsule affects the disease free survival and overall survival rates and the prognostic factors of hepatocellular carcinoma without fibrous capsule after hepatic resection. Methods Clinical data of 210 consecutive patients who had one HCC of diameter ≤5 cm and underwent curative hepatic resection between 2001 and 2009 were retrospectively analyzed. The clinicopathologic features of hepatocellular carcinoma with and without fibrous capsule were compared by using student＇s t test or X2 test. Overall survival and disease-free survival rates were calculated by the Kaplan-Meier method,and differences in survival between the groups were compared using the log-rank test. Postoperative prognostic factors of hepatocellular carcinoma without fibrous capsule were evaluated by univariate and multivariate analysis using Cox＇s proportional hazards model. Results There was no significant difference between hepatocellular carcinoma with and without fibrous capsule in gender, age, liver cirrhosis,Child Pugh, HBsAg, AFP, portal hypertension, AST, ALT, ALB, DBIL and PLT. But hepatocellular carcinoma without fibrous capsule had a significantly higher rate of vascular invasion and poor and moderate differentiation when compared with that with capsule. The 1,3,5-year disease free survival rates of hepatocellular carcinoma absent of capsule were 62.6%,34.2%, 30.8% respectively, which were significantly lower than those of hepatocellular carcinoma with capsule （91.0% ,78.0% ,64.9% ,respectively,P〈0. 001）. The 1,3,5-year overall survival rates of hepatocellular carcinoma absent of capsule were 82.4%, 53.6%, 44.2%, respectively, significantly lower than those of hepatocellular carcinoma with capsule （97.3 %, 88.9 %, 77.3 %, respectively, P〈0. 001 ）. Multivariate analysis revealed that poor and moderate differentiation （HR, 3.181;95% CI,1.428-7.082,P=0.003）,and vascular invasion （HR,4.164;95% CI,2.063-8.405,P〈0.001） were independent unfavorable prognostic factors that would affect disease-free survival of hepatocellular carcinoma without capsule. Child B （HR,3.92;95% CI,1. 176-13. 066,P=0. 026）,poor and moderate differentiation （HR,14. 875;95% CI,2. 039-108. 496, P〈0. 001） and vascular invasion （ HR, 7.112 ; 95 % CI, 3.60- 14.05, P〈0.001） were independent unfavorable prognostic factors that would affect the overall survival of hepatocellular carcinoma without capsule. Conclusion Compared with hepatocellular carcinoma with fibrous capsule,hepatocellular carcinoma without capsule has a higher rate of vascular invasion and poor differentiation,and lower disease-free survival and overall survival rates.