以坏死并血管侵犯为关键要素的肝细胞癌T“N”M分期系统的建立及其准确性初步评估

Establishment of the T“N”M staging system for hepatocellular carcinoma with necrosis plus vascular invasion as an essential component and its preliminary accuracy assessment

目的:通过分析肝细胞癌(肝癌)关键预后因素尝试建立新的肝细胞癌临床分期系统。方法:收集中南大学湘雅医院和广西医科大学附属肿瘤医院肝癌组织标本338例,检测肿瘤坏死和微血管侵犯的发生率;检索的相关文献,分析肝癌伴淋巴结转移的发生率;基于湘雅医院236例肝癌患者随访生存数据,以肿瘤坏死与血管侵犯为变量对肝癌患者复发与生存率进行分析;将肿瘤坏死是否并血管侵犯为要素整合入AJCC第8版肝癌TNM分期系统中,构建T(肿瘤)"N"(坏死+血管侵犯)M(转移)肝癌分期系统,用生存分析比较T"N"M分期与第8版TNM分期的预后判断效力。结果:两组队列中,肿瘤坏死发生率分别为75.4%(177/236)、61/102(59.8%),微血管侵犯检出率分别为71.6%(169/236)、86.2%(88/102),而文献报道肝癌伴淋巴结转移发生率仅为0.8%~8.33%。坏死和血管侵犯联合预测复发及1、3、5年整体生存的ROC曲线下面积分别为0.940、0.834、0.748、0.721。T"N"M分期系统能够清晰区分Ia和Ib、IIIa和IIIc期肝癌患者预后差异。T"N"M分期系统5年生存率的C指数(0.672)和线性趋势χ^2检验值(0.732)高于第8版TNM分期系统对应值(0.537和0.626),而AIC值(1 798.142)则小于TNM分期系统对应值(1 806.256)。结论:所建立的T"N"M分期系统是一个基于肝癌临床病理特征、简单有效的分期系统,可弥补TNM分期系统N分期预测效能的不足,更符合临床实际情况。

Objective: To attempt to establish a new clinical staging system for hepatocellular carcinoma(HCC) based on analysis of the critical prognostic factors for HCC. Methods: A total of 338 HCC specimens were collected from Xiangya Hospital of Central South University and the Affiliated Tumor Hospital of Guangxi Medical University, and then, the presence of tumor necrosis and incidence of microvascular invasion were detected. The incidence of lymph node metastasis in HCC was analyzed through review of the relevant literature. Based on the follow-up survival data of 236 HCC patients in Xiangya Hospital, the recurrence and survival rates of the patients were determined using tumor necrosis and vascular invasion as variables. The T(tumor)"N"(necrosis plus vascular invasion) M(metastasis) staging system was established by integrating the tumor necrosis with or without concomitant vascular invasion as a component into the AJCC 8 th edition TNM staging system, and then, the efficacy of prognosis judgment of the T"N"M staging system and 8 th edition TNM staging system was compared through survival analysis.Results: In the two HCC cohorts, the incidence of tumor necrosis was 75.4%(177/236) and 59.8%(61/102), and the detection rate of microvascular invasion was 71.6%(169/236) and 86.2%(88/102), respectively. The incidence of HCC with lymph node metastasis was only 0.8%–8.33% reported in the literature. The area under the ROC curve for the recurrence and 1-, 3-and 5-year overall survival of HCC patients was 0.940, 0.834, 0.748 and 0.721, respectively. The prognosis differences among patients with Ia, Ib, IIIa and IIIc HCC were clearly distinguished by the T"N"M staging system. The C index of 5-year survival rate(0.672) and the linear trend χ^2 test value(0.732) were higher while the AIC value(1 798.142) was lower than the corresponding values of the 8 th edition TNM staging system(0.537, 0.626, 1 806.256).Conclusion: The established T"N"M staging system based on the clinical pathological features of HCC is a simple and effective staging system, which can overcome the limitations in predictive efficiency of the N category of the TNM staging system, with more relevance to the actual clinical situation.