门脉高压脾机能亢进对根治性治疗肝癌患者预后的影响

Impact of portal hypertension and hypersplenism on prognosis of hepatocellular carcinoma after curative treatment

目的:探讨不同程度门脉高压脾机能亢进与脾切除对肝癌患者预后影响。方法:回顾性分析2008年1月至2018年1月天津市第三中心医院符合米兰标准并行根治性治疗的403例肝细胞肝癌患者临床资料。依据血小板(platelet,PLT)水平、ALBI分级、APRI、血小板/脾长径比值(PSR)等进行Cox比例风险回归分析,对比合并严重脾亢肝癌患者中仅行肝癌根治者与联合脾切除肝癌根治者间临床资料,采用Kaplan-Meier法进行生存分析。结果:Cox单因素、多因素分析显示,PLT水平是肝癌患者整体生存(overall survival,OS)和无瘤生存(disease free survival,DFS)的独立危险因素。不同血小板水平肝癌患者多因素OS生存曲线具有显著性差异(P=0.013)。PSR、APRI、ALBI分级等肝硬化门脉高压参数也是肝癌预后危险因素。仅行肝癌根治组与联合脾切除肝癌根治组在门脉高压脾亢程度、肝功能分级、肿瘤分期均无显著性差异(P>0.05),生存分析显示,联合脾切除组具有更长的OS(P=0.025),两组1、3、5年生存率分别为100%、98.2%、68.5%和97.1%、79.4%、56.8%。两组DFS比较无显著性差异(P=0.326)。结论:PLT、PSR、APRI、ALBI等临床参数是合并门脉高压脾亢肝癌患者重要预后影响因素。对合并严重脾亢符合米兰标准的肝癌患者,在肝癌根治同时联合脾切除可提高患者OS。

Objective: To investigate the impact of portal hypertention with hypersplenism of different severity and splenectomy on prognosis of hepatocellular carcinoma (HCC). Methods: We retrospectively analyzed the clinical data of 403 patients with HCC who met the Milan criteria and received radical treatment in Tianjin Third Central Hospital from January 2008 to January 2018. Cox proportional risk regression analysis was performed for parameters such as platelet levels (PLT), albumin-bilirubin (ALBI) grade, aspartate aminotransferase- to- platelet ratio index (APRI), and post- sinusoidal resistance (PSR). HCC patients with severe hypersplenism were assigned into two groups according to treatment method: radical treatment for HCC alone and radical treatment for HCC plus splenectomy. Clinical data were compared, and the two groups were evaluated using the Kaplan-Meier survival analysis method. Results: Univariate and multivariate analyses showed that PLT was an independent risk factor for overall survival (OS) and disease-free survival (DFS) in patients with HCC. OS curves differed significantly with different PLT among patients with HCC (P=0.013). Furthermore, parameters of portal hypertension in cirrhosis, such as PSR, APRI, and ALBI grade, were risk factors for HCC prognosis. The degree of portal hypertension and hypersplenism, liver function, and tumor-node-metastasis stage did not differ between the two groups (P> 0.05). Survival analysis showed significantly longer OS in the radical treatment plus splenectomy group (P=0.025). Following were the 1-, 3-, and 5- year survival rates: radical treatment alone group 100%, 98.2%, and 68.5% and radical treatment plus splenectomy group. 97.1%, 79.4%, and 56.8%, respectively. DFS did not differ between the two groups (P=0.326). Conclusions: Clinical parameters, such as PLT,PSR, APRI, and ALBI grade, are important prognostic factors in HCC patients with portal hypertension and hypersplenism. Radical treatment for HCC plus splenectomy can improve OS in HCC patients within the Milan criteria with severe hypersplenism.