结合营养风险筛查2002构建预测肝细胞癌患者复发的Nomogram模型

Nomogram model of prognosis of hepatocellular carcinoma patients was constructed based on NRS-2002

目的:采用营养风险筛查2002(nutritional risk screening,2002)评估肝细胞癌(hepatocellular carcinoma,HCC)患者营养状态并结合其他危险因素构建预测HCC患者复发的Nomogram模型。方法:回顾性分析濉溪县医院、北京朝阳急诊抢救中心、空军特色医学中心在2015年7月至2019年1月期间行肝切除术治疗的241例HCC患者的临床资料。采用单因素和多因素Cox比例风险模型分析HCC患者复发及死亡的独立危险因素。根据独立危险因素构建Nomogram模型。采用内部数据进行Nomogram模型效能验证。结果:根据HCC患者是否死亡对相关变量进行受试者操作特征曲线(receiver operator characteristic curve,ROC曲线)分析。年龄、甲胎蛋白(alpha-fetoprotein,AFP)、总胆红素(total bilirubin,TBIL)、谷丙转氨酶(alanine aminotransferase,ALT)及白蛋白(albumin,ALB)的曲线下面积(area under the curve,AUC)分别为0.783、0.715、0.758、0.729、0.822;最佳截断值分别65岁、400μg/L、34.67μmol/L、40.54U/L、35g/L。营养不良患者的肝硬化、TBIL(>34.67μmol/L)及ALB(≤35g/L)比例高于营养正常患者(P <0.05)。随访末期,241例HCC患者中复发127例,中位无复发存活时间14个月,死亡101例,中位存活时间19个月。营养正常的无复发生存率及总体生存率均高于营养不良患者(P <0.05)。多因素Cox风险比例模型分析结果显示:肝硬化、肿瘤最大直径(>5cm)、TNM分期(Ⅲ+Ⅳ)、TBIL(>34.67μmol/L)及NRS-2002(营养不良)是HCC患者复发的独立危险因素(P <0.05);肝硬化、肿瘤最大直径(>5cm)、TNM分期(Ⅲ+Ⅳ)是HCC患者死亡的独立危险因素(P<0.05)。内部验证结果显示:6个月无复发生存率、12个月无复发生存率、24个月无复发生存率的C-index分别为0.716(95%CI:0.671~0.866)、0.710(95%CI:0.624~0.838)、0.699(95%CI:0.611~0.796)。结论:本研究构建预测HCC患者术后6个月、12个月、24个月无复发生存率的Nomogram模型效能较好,可以根据该模型完善围术期治疗计划。

Objective: The nutritional risk Assessment Form(NRS-2002) was used to assess the nutritional status of patients with hepatocellular carcinoma(HCC) and to construct a Nomogram model to predict the recurrence of HCC patients in combination with other risk factors.Methods: The clinical data of 241 patients with HCC underwent hepatectomy in Suixi County People’s Hospital, Beijing Chaoyang Emergency Rescue Center and Air Force Characteristic Medical Center from July 2015 to January 2019 were retrospectively analyzed. Univariate and multivariate Cox proportional risk models were used to analyze the independent risk factors for recurrence and death of HCC patients. Nomogram model was constructed according to independent risk factors.Internal data were used to verify the effectiveness of the Nomogram model.Results: ROC curve was used to analyze the correlation variables according to the mortality of HCC patients.The AUC of age, AFP, TBIL, ALT and ALB were 0.783, 0.715, 0.758, 0.729 and 0.822, respectively.The optimal truncation values were 65 years、400μg/L、34.67μmol/L、40.54 U/L、35 g/L, respectively.The proportion of cirrhosis(yes), TBIL(>34.67μmol/L) and ALB( ≤ 35 g/L)in patients with malnutrition was higher than that in patients with normal nutrition(P< 0.05).At the end of follow-up, 127 of the 241 HCC patients relapsed, with a median relapse-free survival of 14 months and 101 deaths of 19 months.The relapse-free survival rate and overall survival rate of nutritionally normal patients were higher than that of malnutrition patients(P < 0.05).Multiariable Cox risk proportion model analysis results showed that liver cirrhosis(YES), tumor diameter(>5 cm), TNM staging( Ⅲ + Ⅳ), TBIL(>34.67 μmol) and NRS-2002(malnutrition) are independent risk factors for recurrence of HCC patients(P < 0.05);Cirrhosis of the liver(YES), tumor diameter(>5 cm), TNM staging( Ⅲ + Ⅳ)are the independent risk factors of death in patients with HCC(P < 0.05).The results of internal validation showed that the 6 month, 12 month and 24 month recurrence free survival rates were 0.716(95%CI: 0.671-0.866), 0.710(95%CI: 0.624-0.838) and 0.699(95%CI: 0.611-0.796), respectively.Conclusion: In this study, the Nomogram model was effective in predicting the recurrence free survival rate of HCC patients at 6, 12, and 24 months after surgery, which could be used to improve the perioperative treatment plan.