肝细胞癌AJCC第8版TNM分期中T分期的验证与修改建议

Verification and proposed modification on T staging of the AJCC TNM staging system(8th edition) for hepatocellular carcinoma

目的最近美国癌症联合委员会(AJCC)将肝细胞癌TNM分期更新至第8版,推动了新一轮肝癌诊断和治疗的发展。但该分期是否已尽善尽美,仍须大量临床数据的支持。复旦大学附属中山医院通过长期的临床随访资料来验证AJCC第8版肝细胞癌TNM分期,并对其不足提出修改建议。方法将2006—2007年在复旦大学附属中山医院肝外科接受根治性切除并且术后病理学检查明确的肝细胞癌病人随机选取658例作为研究对象。按照TNM分期及基于该分期的修改将研究对象分组,通过生存分析比较各组间的生存差异,并利用ROC曲线评价其预后判断效力。结果单发肿瘤直径≤2 cm的病人,血管侵犯仍然显著影响病人的预后,这与第8版TNM分期存在差异。随着单发肿瘤的增大,发生血管侵犯的比例也在逐步上升,肿瘤直径>5 cm,血管侵犯发生率则增加1倍。单发肿瘤直径>5 cm的病人其总存活率和无瘤存活率显著低于肿瘤直径≤5 cm的病人,提示肿瘤直径为5 cm是T分期的一个重要指标,可能成为第8版TNM分期标准的补充。因此,复旦大学附属中山医院以肿瘤直径是否>5 cm和是否伴有血管侵犯为关键因素,对第8版TNM分期中的T分期做了调整。生存曲线和ROC曲线显示修改后的分期方法能更有效地评估肝细胞癌的严重程度和病人的预后。结论 AJCC第8版TNM分期为临床诊疗提供了重要的指导依据,但仍存在值得讨论和完善之处,须进一步的深入研究。

Objective The American Joint Committee on Cancer （AJCC） has updated the TNM staging system of hepatocellular carcinoma （8th Edition）to improve the diagnosis and treatment of liver cancer. However,it needs to be supported by abundant clinical data. The study aimed to test the staging system with the long-term database and put forward some proposals. Methods In the study, 658 HCC patients were randomly selected from patients who had received a curative hepatectomy from 2006 to 2007 and grouped according to TNM staging system and modified version. Survival analysis were used to compare the prognosis between patients in different groups and the area under the ROC curve was applied to assess the predictive effect of staging system. Results In the patients with a tumor ≤ 2cm, the vascular invasion still significantly affected the prognosis, which was not consistent with the 8th Edition of staging system. As the tumor enlarged, the incidence of vascular invasion increased, especially when the tumor 〉5 cm. Furthermore, the patients with a tumor 〉5 cm had worse survival than those with a tumor ≤5 cm, indicating that 5 cm might be an important cutoff in T stage and a new standard of TNM staging system. Thus,the authors made an adjustment on the T staging system according to tumor size and vascular invasion. Survival and ROC curves showed that the modified version predicted the prognosis of HCC more accurately. Conclusion The 8th edition of the TNM staging system provides the guidance in clinical practice, but it still needs to be improved.