肝左外叶切除和左半肝切除对左外叶肝细胞癌患者预后的影响

Impact of left lateral lobectomy and left hepatectomy on prognosis of patients with hepatocellular carcinoma located in left lateral lobe

目的探讨肝左外叶切除和左半肝切除对左外叶肝细胞癌(HCC)患者预后的影响。方法选取2011年1月至2013年1月于我院接受左外叶或左半肝切除的278例左外叶HCC患者作为研究对象,其中行左外叶切除患者223例、行左半肝切除患者55例,所有患者术后均接受随访。应用Kaplan-Meier法绘制并比较行左外叶切除或左半肝切除患者的总体生存、肿瘤复发曲线,采用单因素和多因素Cox回归分析患者预后的影响因素。结果多因素Cox回归分析结果显示,窄切缘(HR=1.427,95%CI 1.014~2.006,P=0.041;HR=1.441,95%CI 1.062~1.955,P=0.019)、微血管侵犯阳性(HR=1.598,95%CI 1.137~2.246,P=0.007;HR=1.374,95%CI 1.018~1.854,P=0.038)、肿瘤直径≥5 cm(HR=1.691,95%CI 1.188~2.408,P=0.004;HR=1.359,95%CI 1.003~1.841,P=0.048)、肿瘤多发(HR=1.855,95%CI 1.211~2.840,P=0.005;HR=1.950,95%CI 1.327~2.863,P=0.001)是患者术后总体生存和肿瘤复发的独立危险因素。左外叶切除和左半肝切除患者术后1、3、5年的总体生存率分别为89.7%、64.5%、45.5%和90.9%、72.7%、52.2%(P=0.329),术后1、3、5年的肿瘤复发率分别为18.4%、53.4%、71.5%和14.5%、41.8%、62.1%(P=0.146),差异均无统计学意义。宽切缘的左外叶切除和左半肝切除患者术后1、3、5年的总体生存率分别为92.3%、71.5%、53.1%和90.9%、72.7%、52.2%(P=0.965),术后1、3、5年的肿瘤复发率分别为13.8%、45.4%、67.1%和14.5%、41.8%、62.1%(P=0.605),差异均无统计学意义。窄切缘的左外叶切除和左半肝切除患者术后1、3、5年的总体生存率分别为86.0%、54.8%、34.9%和90.9%、72.7%、52.2%(P=0.036),术后1、3、5年的肿瘤复发率分别为24.7%、64.5%、77.7%和14.5%、41.8%、62.1%(P=0.013),差异均有统计学意义。左外叶切除和左半肝切除患者术后总体并发症的发生率分别为16.1%(36/223)、20.0%(11/55),Ⅲ/Ⅳ级术后并发症的发生率分别为1.8%(4/223)、3.6%(2/55),差异均无统计学意义(P均>0.05)。结论手术方式不是左外叶HCC预后的独立危险因素,但肿瘤邻近门静脉矢状部,行左外叶切除只能获得窄切缘时,建议行左半肝切除。

Objective To investigate the impact of left lateral lobectomy and left hepatectomy on the prognosis of patients with hepatocellular carcinoma(HCC)located in the left lateral lobe.Methods A total of 278 patients with HCC located in the left lateral lobe who underwent left lateral lobectomy(n=223)or left hepatectomy(n=55)in our hospital from Jan.2011 to Jan.2013 were enrolled.All patients were followed up after operation.The overall survival(OS)and tumor recurrence(TR)curves of patients who underwent left lateral lobectomy or left hepatectomy were drawn and compared by Kaplan-Meier method.The prognostic factors were analyzed by univariate and multivariate Cox regression analyses.Results Multivariate Cox regression analysis showed that narrow margin(hazard ratio[HR]=1.427,95%confidence interval[CI]1.014-2.006,P=0.041;HR=1.441,95%CI 1.062-1.955,P=0.019),microvascular invasion(MVI)positive(HR=1.598,95%CI 1.137-2.246,P=0.007;HR=1.374,95%CI 1.018-1.854,P=0.038),tumor size≥5 cm(HR=1.691,95%CI 1.188-2.408,P=0.004;HR=1.359,95%CI 1.003-1.841,P=0.048)and multiple tumors(HR=1.855,95%CI 1.211-2.840,P=0.005;HR=1.950,95%CI 1.327-2.863,P=0.001)were independent risk factors for OS and TR.The 1-,3-and 5-year OS rates of patients who underwent left lateral lobectomy and left hepatectomy were 89.7%,64.5%,45.5%and 90.9%,72.7%,52.2%,respectively(P=0.329),and the 1-,3-and 5-year TR rates were 18.4%,53.4%,71.5%and 14.5%,41.8%,62.1%,respectively(P=0.146).The 1-,3-and 5-year OS rates of patients who underwent left lateral lobectomy and left hepatectomy with wide margin were 92.3%,71.5%,53.1%and 90.9%,72.7%,52.2%,respectively(P=0.965),and the 1-,3-and 5-year TR rates were 13.8%,45.4%,67.1%and 14.5%,41.8%,62.1%,respectively(P=0.605).The 1-,3-and 5-year OS rates of patients who underwent left lateral lobectomy and left hepatectomy with narrow margin were 86.0%,54.8%,34.9%and 90.9%,72.7%,52.2%,respectively(P=0.036),and the 1-,3-and 5-year TR rates were 24.7%,64.5%,77.7%and 14.5%,41.8%,62.1%,respectively(P=0.013).The overall postoperative complications and gradeⅢ/Ⅳcomplications between the left lateral lobectomy and left hepatectomy were 16.1%(36/223)vs 20.0%(11/55)and 1.8%(4/223)vs 3.6%(2/55),respectively(both P>0.05).Conclusion Surgical method is not an independent risk factor for the prognosis of patients with HCC located in the left lateral lobe.However,if the tumor is close to the sagittal part and a wide margin cannot be ensured during left lateral lobectomy,left hepatectomy is recommended.