控制手术相关危险因素后肝癌术后复发危险因素分析

Analysis of risk factors of recurrence of hepatocellular carcinoma after control of surgical-risk-factors

目的探讨在控制手术相关危险因素后，肝细胞癌（HCC）患者术后复发的临床病理因素。方法回顾性分析在肝区域血流选择性阻断下R0切除、失血量〈800ml、无围手术期输血的288例HCC患者的临床资料。结果全组复发123例，中位无复发时间为36个月，其1、3、5年无复发生存率分别为74．9％、49．3％和34．3％。单因素分析显示，血清丙氨酸转氨酶、甲胎蛋白水平、肿瘤直径、多发病灶、卫星结节、分化程度、脉管瘤栓、包膜侵犯、术后肝功能不全、术前介入治疗、术后介入治疗与HCC患者的术后复发有关。多因素分析显示，肿瘤直径、卫星结节、脉管瘤栓、分化程度和术后肝功能不全为影响HCC患者术后复发的独立因素。在至少具有一个高危复发因素的158例患者中，是否接受术前、术后介入治疗患者的中位无复发生存时间差异均无统计学意义（均P〉0．05）。结论控制手术相关危险因素后，肿瘤特征是HCC患者术后无复发生存时间的主要影响因素；术前、术后介入治疗不能使完整切除肿瘤的患者获益。

Objective RO resection, Pringle maneuver, intraoperative massive blood loss and perioperative blood transfusion have been definitely recognized to be surgery-related risk factors of recurrence of hepatocellular carcinoma （ HCC ） in recent years. The aim of this study was to investigate the post- operative risk factors of recurrence of HCC after control of the above mentioned risk factors. Methods 288 consecutive HCC patients underwent hepatectomy with selective regional vascular occlusion by the same surgical team. All patients had R0 resection, less than 800 ml blood loss and had no perioperative blood transfusion. The clinical and pathological factors were retrospectively analyzed. Results The total 1-year, 3-year and 5-year disease-free survival rate （DFS） was 74. 9%, 49. 3% and 34. 3%, respectively. Univariate analysis showed that serum gamma-glutamyl-transferase rise 〉 55 U/L, AFP 〉 400 ng/ml, tumor diameter 〉 5 cm, multi-focal lesions, satellite nodules, poor differentiation, microvascular invasion, envelope invasion, postoperative liver insufficiency, preoperative TACE and postoperative TACE were significantly associated with poor DFS. Multivariate Cox analyses revealed that tumor size, satellite nodules, poor differentiation, microvascular invasion and postoperative liver insufficiency were independent prognostic predictors associated with shorter DFS. According to the results of multivariate Cox analysis of 158 cases with at least one risk factor selected from the whole group, further analysis demonstrated that perioperative TACE was not significantly associated with the median DFS （P 〉 0. 05 for all）. Conclusions Selective regional vascular occlusion may effectively control the surgiury-related risk factors of recurrence of HCC. Tumor features are the main affecting factors of DFS. Preoperative or postoperative TACE do not benefit patients who received curative resection.