经皮微波消融早期原发性肝癌预后因素分析

Microwave ablation of early-stage hepatocellular carcinoma affects survival prognostic factors

目的探讨经皮微波消融(US-PMMA)治疗早期肝癌(HCC)患者生存预后的高危因素,及对术后总生存率(OS)、肿瘤特异性生存率(CSS)和无病生存率(DFS)的影响。方法回顾性分析2002年1月至2017年12月在中国人民解放军总医院介入超声科行US-PMMA治疗的HCC患者1563例。依据WHO对年龄的界定,以60岁及以上为老年组共733例,60岁以下为青年组共830例。所有病灶均为首次接受US-PMWA。收集患者及病灶基线资料,使用单变量和多变量Cox回归模型及倾向性评分匹配(PSM)分析OS、DFS和CSS基线特征的危险比(HR)。OS、DFS和CSS以Kaplan-Meier曲线表示,用Log-rank检验比较。结果与青年组HCC相比,老年组HCC更易罹患低白蛋白血症、低血红蛋白血症以及较多合并症,但肝硬化发生少、肝功能较好。经PSM后,肿瘤长径(95%CI=1.1-1.4,P<0.001)及数量(95%CI=1.2-1.9,P<0.001)、γ-谷氨酰转移酶(γ-GT)(95%CI=1.0-1.0,P<0.001)和甲胎蛋白(AFP)(HR为1.5,95%CI=1.2-1.8,P<0.001)是OS、CSS和DFS的共同预测因子。年龄(95%CI=1.2-1.8,P<0.001)和中性粒细胞与淋巴细胞比率(NLR)(95%CI=1.0-1.0,P=0.043)是OS和CSS的另外两个预测因子。白蛋白可预测OS,而性别和肝硬化可预测DFS。在随访期间(12-156个月),Log-rank检验表明,所有预测因子均显著影响OS、CSS或DFS(均P<0.01)。其中,多发肿瘤对OS、CSS和DFS的影响最大,与单发病灶患者比较,多发病灶患者12年OS、CSS和DFS分别降低了9.2%、2.5%和4.1%,中位生存期分别缩短12.3个月、25.0个月和11.3个月。结论不同类型早期HCC患者微波消融后预后获益不同。在影响长期生存和疾病进展的众多高危因素中,纠正低蛋白血症和肝功能对改善早期HCC患者US-PMWA后预后具有重要临床意义。

Objective To identify the risk factors for survival prognosis of patients with early-stage hepatocellular carcinoma(HCC)after ultrasound-guided percutaneous microwave ablation(US-PMMA),and to compare the overall survival(OS),cancer specific survival(CSS)and disease-free survival(DFS)between different early-stage HCC patients.Methods A total of 1563 patients with early-stage hepatocellular carcinoma(HCC)who underwent MWA in the interventional ultrasound department of the Chiese PLA General Hospital from January 2002 to December 2017 were retrospectively analyzed.Propensity score matching(PSM)balanced the baseline parameters between the elderly group(≥60 years)and the young group(<60 years).Multivariate Cox regression analysis was used to identify the risk factors of OS,CSS and DFS.OS,CSS and DFS probabilities for different patients stratified by respective predictors were calculated with Kaplan-Meier method and compared using the Log-Rank test.Results All parameters were balanced except for age after PSM.Tumor diameter(95%CI=1.1-1.4,P<0.001),number of tumors(95%CI=1.2-1.9,P<0.001),γ-GT(95%CI=1.0-1.0,P<0.001)and AFP(HR=1.5,95%CI=1.2-1.8,P<0.001)were shared predictors for OS,CSS and DFS.Age(95%CI=1.2-1.8,P<0.001)and neutrophile to lymphocyte ratio(NLR)(95%CI=1.0-1.0,P=0.043)were another two predictors for both OS and CSS.Albumin predicted OS only,and sex and cirrhosis just predicted DFS.Over the follow-up period(12-156 months),log-rank tests showed that all predictors significantly affected the corresponding OS,CSS or DFS(all P<0.01).Among them,multiple tumors had the greatest impact on OS,CSS and DFS.Compared with patients with single lesion,OS,CSS and DFS in patients with multiple lesions decreased by 9.2%,2.5%and 4.1%respectively at the 12 years of follow-up,and the median survival time was shortened by 12.3 months,25.0 months and 11.3 months,respectively(log-rank P=0.049 for OS;P=0.007 for CSS;P<0.001 for DFS).Conclusions The prognostic benefits from MWA treating early-stage HCC in patients with different survival risk factors are different.Clinically feasible correction of hypoproteinemia and liver disfunction are of great significance to improve the prognosis of early-stage HCC patients after US-PMMA.