肝细胞癌破裂危险因素及其行肝切除术后临床预后分析

Predictors and clinical outcomes for spontaneous rupture of hepatocellular carcinoma among patients undergoing partial hepatectomy

目的探讨肝细胞癌(以下简称肝癌)破裂行根治性肝切除术后的独立预测因素,分析肿瘤破裂本身对肝癌接受肝切除术预后的影响。方法回顾分析2007年4月至2011年11月海军军医大学东方肝胆外科医院和武汉大学中南医院接受肝切除治疗的106例肝癌破裂病人(破裂组)和201例肝癌病人(未破裂组)的临床病理资料,采用倾向性评分和多元logistic回归统计分析比较两组病人的临床资料、预后及相关因素。结果伴有高血压、肝硬化、总胆红素水平、肿瘤大小和腹腔积液与肝癌破裂独立相关。倾向性评分匹配前所有307例肝癌病人1、3、5年总体生存率分别为54.0%、37.3%和33.8%,破裂组1、3、5年总体生存率分别为37.7%、19.6%、14.7%低于未破裂组(分别为82.8%、58.3%、43.0%)(P<0.001),两组1、3、5年无瘤生存率分别为44.5%、29.7%、19.4%和66.6%、44.1%、30.1%,差异亦有统计学意义(P=0.0077)。倾向性评分匹配后破裂组和未破裂组1、3、5年总体生存率分别为41.5%、23.5%、17.5%和70.8%、47.1%、37.6%;两组1、3、5年无瘤生存率分别为50.4%、35.1%、27.1%和55.4%、38.2%、27.4%。倾向性评分匹配前后单、多因素分析均显示,肝癌破裂与病人总体生存独立相关,但与病人无瘤生存无相关性。倾向性评分匹配前后两组病人手术期并发症发生率及医院死亡率差异无统计学意义(P均>0.05)。结论伴有高血压、肝硬化、高水平的总胆红素、肿瘤直径>5 cm及腹腔积液是肝癌破裂的独立危险因素。肝癌破裂本身是影响肝切除术肝癌病人总体生存的独立预后因素,但不是病人无瘤生存的独立预后因素。肝癌破裂与否并未影响肝癌病人行肝切除术后并发症发生率及死亡率。

Objective To explore the independent predictive factors of spontaneous tumor rupture(STR) after curative resection of hepatocellular carcinoma(HCC),and to investigate the impact of STR HCC on long-term survival after resection.Methods The clinicopathological parameters of 106 patients with ruptured HCC and 201 patients with nonruptured HCC who underwent hepatic resection from April 2007 to November 2011 at Eastern Hepatobiliary Surgery Hospital,the Second Military Medical University and Zhongnan Hospital of Wuhan University were retrospectively analyzed.Propensity scores and logistic regression analysis were used to compare the clinical features and factors associated with the prognosis between tumor rupture group and non-rupture group.Results Hypertension,liver cirrhosis,total bilirubin,tumor size,and ascites were independent prognostic factors for patients with ruptured HCC.The 1-,3-and 5-year overall survival rates for all 307 patients-were 54.0%,37.3% and 33.8%respectively.The ruptured HCC group had significantly lower overall survival rates(37.7%,19.6% and 14.7% at 1,3 and 5 years respectively)than the non-ruptured HCC group(82.8%,58.3%and 43.0 %),P <0.001.There was also a significant difference in recurrence free survival(RFS) between the ruptured(44.5%,29.7% and 19.4% at 1,3 and 5 years respectively) and non-ruptured(66.6%,44.1% and 30.1%),P=0.0077.After propensity matching,the 1-,3-,and 5-year overall survival(OS) in the rupture group were 41.5%,23.5% and17.5% and non-rupture groups were 70.8%,47.1% and 37.6%,respectively,while the 1-,3-,and 5-year RFS rates in the rupture were 50.4%,35.1%,27.1% and non-rupture groups were 55.4%,38.2%,27.4%,respectively.STR was significant associated with increased risk of OS,while it was not significantly associated with increased risks of shorter RFS.No significant difference in morbidity and mortality was found between both groups.Conclusion The presence of hypertension,liver cirrhosis,higher total bilirubin levels,tumor size> 5 cm,and presence of ascites are the independent indicators of poorer prognosis for patients undergoing hepatic resection after ruptured HCC.STR was an independent risk factor influencing OS,while not RFS of patients with HCC following partial hepatectomy.Tumor rupture does not affect the morbidity and mortality rate of STR patients after hepatectomy.