肝细胞癌肝切除术的临床疗效及预后因素分析

Clinical efficacy and prognostic factors analysis of hepatectomy for hepatocellular carcinoma

目的探讨肝细胞癌(以下简称肝癌)肝切除术的临床疗效和预后影响因素。方法采用回顾性病例对照研究方法。收集2009年1月至2016年1月电子科技大学临床医学院附属四川省肿瘤医院收治的789例肝癌患者的临床病理资料;男669例,女120例;中位年龄为52岁,年龄范围为42~60岁。根据患者术前和术中综合评估选择手术方式。观察指标:(1)手术治疗情况。(2)术后病理学检查情况。(3)随访和生存情况。(4)预后因素分析。采用门诊或电话方式进行术后随访,了解患者生存情况。随访时间截至2017年5月。计量资料采用K-S检验正态性,偏态分布的计量资料以M(范围)表示。计数资料以绝对数或百分比表示。采用Kaplan-Meier法计算生存率并绘制生存曲线。单因素分析采用Log-rank检验,多因素分析采用COX回归模型。结果(1)手术治疗情况:789例患者均施行肝切除术,切除肝脏体积占肝脏总体积32.5%(17.0%~52.0%);其中解剖性肝切除术413例(解剖性肝段切除术116例、右半肝切除术136例、左半肝切除术77例、肝左外叶切除术57例、肝中叶切除术27例),非解剖性肝切除术376例(局部肝切除术344例、扩大右半肝切除术17例、扩大左半肝切除术15例)。789例患者术中出血量为400mL(200~500mL),其中术中输血治疗173例。789例患者中,240例术后发生并发症(严重并发症68例),其中肝功能不全65例,腹腔和胸腔积液37例,肺部并发症37例,感染性并发症19例,心血管并发症17例,腹腔出血17例,胃肠道并发症11例,神经系统并发症9例,术后胆汁漏8例,其他并发症10例,死亡11例(同1例患者可合并多种并发症);229例经对症支持治疗后均痊愈。789例患者术后住院时间为9d(7~11d)。(2)术后病理学检查情况。789例患者术后病理学检查结果显示:17例合并胆管癌栓,92例合并门静脉分支肉眼癌栓,167例合并微血管侵犯;肿瘤分化程度为高分化19例,中分化678例,低分化92例。(3)随访和生存情况:789例患者中,690例获得术后随访,随访时间为1~96个月,中位随访时间为21个月。789例患者术后1、3、5年总体生存率分别为82.1%、66.1%、59.2%。(4)预后因素分析。单因素分析结果显示:术前甲胎蛋白水平、术前肝功能Child分级、巴塞罗那临床肝癌分期、肿瘤直径、肝切除方式、术中出血量、术中输血治疗、术后并发症、术后严重并发症、胆管癌栓、门静脉癌栓、微血管侵犯是影响行肝癌肝切除术患者术后预后的因素(χ^2=8.603,8.864,39.970,28.978,6.376,26.144,8.955,6.596,9.910,7.288,37.566,19.183,P<0.05)。多因素分析结果显示:肿瘤直径、术中出血量、门静脉癌栓是影响行肝癌肝切除术患者术后预后的独立因素(风险比=1.085,1.000,2.259,95%可信区间为1.053~1.118,1.000~1.001,1.621~3.146,P<0.05)。结论肝癌肝切除术具有良好的安全性,临床疗效满意。肿瘤直径、术中出血量、门静脉癌栓是影响行肝癌肝切除术后患者预后的独立因素。

Objective To investigate the clinical efficacy and prognostic factors of hepatectomy for hepatocellular carcinoma(HCC).MethodsThe retrospective case-control study was conducted.The clinico-pathological data of 789 HCC patients who were admitted to the Sichuan Cancer Hospital Affiliated to School of Medicine of University of Electronic Science and Technology of China from January 2009 to January 2016 were collected.There were 669 males and 120 females,aged from 42 to 60 years,with a median age of 52 years.Surgical procedures were determined according to the preoperative and intraoperative comprehensive evaluations of patients.Observation indicators:(1)situations of surgical treatment;(2)postoperative pathological examinations of patients;(3)follow-up and survival situations;(4)prognostic factors analysis.Follow-up using outpatient examination and telephone interview was performed to detect patients′survival up to May 2017.Normality of measurement data was done using the K-S test.Measurement data with skewed distribution were represented as M(range).Count data were described as absolute number or percentage.The survival rate and survival curve were respectively calculated and drawn by the Kaplan-Meier method.The univariate analysis and multivariate analysis were done using the Log-rank test and COX regression model,respectively.Results(1)Situations of surgical treatment:all the 789 patients underwent successful hepatectomy,liver volume dissected accounting for 32.5%(range,17.0%-52.0%)of the total liver volume.Of the 789 patients,413 underwent anatomical hepatectomy including 116 of hepatic segmentectomy,136 of right hemihepatectomy,77 of left hemihepatectomy,57 of left lateral lobe hepatectomy,27 of central hepatectomy,376 underwent nonanatomical hepatectomy including 344 of partial hepatectomy,17 of extended right hemihepatectomy,15 of extended left hemihepatectomy.Volume of intraoperative blood loss was 400 mL(range,200-500 mL)in the 789 patients and 173 had intraoperative blood transfusion.Of the 789 patients,240 had postoperative complications(68 with postoperative severe complications),including 65 of liver insufficiency,37 of ascites and pleural effusion,37 of pulmonary complications,19 of infectious complications,17 of cardiovascular complications,17 of abdominal hemorrhage,11 of gastrointestinal complications,9 of neruologic complications,8 of postoperative bile leakage,10 of other complications,11 of death;the same patient can merge multiple complications.The 229 survival patients with complications were cured by symptomatic supportive treatment.Duration of postoperative hospital stay was 9 days(range,7-11 days).(2)Postoperative pathological examinations.Results of postoperative pathological examinations showed 17 patients with bile duct tumor thrombus,92 with naked eye tumor thrombus at portal vein branches and 167 with microvascular invasion.Of the 789 patients,High-,moderate-,low-differentiated carcinoma were detected in 19,678,92 patients,respectively.(3)Follow-up and survival situations:690 of the 789 patients were followed up for 1-96 months,with a median time of 21 months.The 1,3,5-year overall survival rates were 82.1%,66.1%,59.2%in the 789 patients.(4)Prognostic factors analysis:results of univariate analysis showed that level of preoperative alphafetoprotein(AFP),Child grade of preoperative liver function,Barcelona clinic liver cancer staging,tumor diameter,surgical procedure of hepatectomy,volume of intraoperative blood loss,intraoperative blood transfusion,postoperative complications,postoperative severe complications,bile duct tumor thrombus,portal vein tumor thrombus,vascular invasion were related factors affecting prognosis of HCC patients after hepatectomy(χ^2=8.603,8.864,39.970,28.978,6.376,26.144,8.955,6.596,9.910,7.288,37.566,19.183,P<0.05).Results of multivariate analysis showed that tumor diameter,volume of intraoperative blood loss,portal vein tumor thrombus were independent factors affecting prognosis of HCC patients after hepatectomy(hazard ratio=1.085,1.000,2.259,95%confidence interval:1.053-1.118,1.000-1.001,1.621-3.146,P<0.05).ConclusionHepatectomy for HCC has a good safety,with satisfactory clinical efficacy.Tumor diameter,volume of intraoperative blood loss,portal vein tumor thrombus are independent factors affecting prognosis of HCC patients after hepatectomy.