碱性磷酸酶与前白蛋白比值对肝细胞癌根治性切除术后患者预后及并发症的预测价值

Predictive value of preoperative alkaline phosphatase to prealbumin ratio in prognosis and postoperative complications in patients with hepatocellular carcinoma after radical tumor resection

目的研究术前碱性磷酸酶(ALP)与前白蛋白(PA)比值(APR)对肝细胞癌(HCC)根治性切除术后预后及并发症的预测价值。方法回顾性分析2013年1月—2021年8月于西南医科大学附属医院肝胆外科行HCC根治性切除术的217例患者的临床病理资料。采用X-tile软件获取APR最佳截断点。采用χ^(2)检验分析术前APR与患者临床病理特征之间的关系。采用Kaplan-Meier法绘制生存曲线,通过Log-rank检验比较不同组别的差异。采用单因素、多因素Cox回归模型分析影响预后的独立因素。采用单因素、多因素Logistic模型分析影响术后重症并发症的独立因素。通过ROC曲线判断APR对术后并发症的预测价值。ROC曲线下面积的比较采用配对比较的方法。结果APR的最佳截断点为0.5,将患者分为低APR组111例,高APR组106例。与低APR组相比,高APR组患者中ALT>50 U/L、Alb<40 g/L、CNLCⅢ期、开腹手术途径、肝硬化、多个肿瘤、术后并发症及重症并发症的比例明显增高(P值均<0.05)。低APR组的1、3、5年总生存率为86.0%、74.9%、71.3%,高APR组的1、3、5年总生存率为79.2%、57.5%、47.0%,高APR组的总生存率低于低APR组(χ^(2)=9.825,P=0.002)。多变量Cox回归分析显示,AFP(HR=1.774,95%CI:1.107~2.843,P=0.017)、CNLC分期(HR=2.708,95%CI:1.514~4.844,P=0.001)、肿瘤大小(HR=1.696,95%CI:1.060~2.714,P=0.028)和APR(HR=2.022,95%CI:1.244~3.285,P=0.004)是HCC根治性切除术后患者总生存期的独立危险因素。低APR组的1、3、5年无复发生存率为82.3%、69.4%、61.3%,高APR组的1、3、5年无复发生存率为76.2%、54.4%、44.2%,高APR组的无复发生存率低于APR低组(χ^(2)=5.769,P=0.016)。多变量Cox回归分析显示,CNLC分期(HR=2.509,95%CI:1.423~4.422,P=0.001)、肿瘤大小(HR=1.725,95%CI:1.119~2.660,P=0.014)和APR(HR=1.619,95%CI:1.037~2.527,P=0.034)是HCC根治性切除术后患者无复发生存期的独立危险因素。多因素Logistic回归分析结果显示,高血压(OR=3.090,95%CI:1.385~6.893,P=0.006)、开腹手术(OR=4.198,95%CI:1.779~9.907,P=0.001)、肝硬化(OR=2.376,95%CI:1.194~4.729,P=0.014)和APR(OR=2.151,95%CI:1.160~3.986,P=0.015)是HCC术后重症并发症发生的独立危险因素。APR、ALP和PA对患者术后重症并发症预测的曲线下面积分别为0.625(95%CI:0.547~0.702)、0.613(95%CI:0.534~0.693)和0.554(95%CI:0.474~0.634)。结论APR可用于预测HCC根治性切除术后患者的预后及重症并发症。

Objective To explore the predictive value of preoperative alkaline phosphatase to prealbumin ratio(APR)in prognosis and postoperative complications for patients with hepatocellular carcinoma(HCC)after radical tumor resection.Methods A total of 217 HCC patients who underwent radical tumor resection in the Department of Hepatobiliary Surgery of the Affiliated Hospital of Southwest Medical University from January 2013 to August 2021 were retrospectively recruited and their clinical data were statistically analyzed.The X-tile software was used to obtain the optimal cutoff value of APR.The χ^(2) test was conducted to analyze association between preoperative APR and other clinicopathological characteristics.The Kaplan-Meier curve was plotted and the Log-rank test was performed to analyze survival of patients.The univariate and multivariate Cox proportional hazards regression models were used to analysis factors affecting the prognosis of HCC patients.The univariate analysis and multivariate Logistic regression were used to identify factors related with postoperative complications.The receiver operating characteristic(ROC)curve was used to determine the predicting value of APR.Results The optimal cutoff value for APR ratio was 0.5 and these 217 patients were divided into the low-and high APR groups(111 vs 106 cases)accordingly.Compared with the low-APR group,the proportion of patients with ALT(>50 U/L),Alb(<40 g/L),the CNLC of the III stage,open surgery,liver cirrhosis,multiple tumor lesions,postoperative complication,and major complication were significantly increased in the high-APR patients(all P<0.05).Moreover,the 1-,3-,and 5-year OS were 86.0%,74.9%,and 71.3%,respectively in the low-APR patients,while the numbers were 79.2%,57.5%,and 47.0%,respectively,in the high-APR patients,indicating that patients in high-APR group had significantly worse OS(P=0.002).AFP(HR=1.774,95%CI:1.107-2.843,P=0.017),CNLC stage(HR=2.708,95%CI:1.514-4.844,P=0.001),tumor size(HR=1.696,95%CI:1.060-2.714,P=0.028),and APR(HR=2.022,95%CI:1.244-3.285,P=0.004)were all independent risk predictors for OS.The 1-,3-,and 5-year RFS were 82.3%,69.4%,and 61.3%,respectively,in the low-APR patients,whereas the numbers were 76.2%,54.4%,and 44.2%,respectively in the high-APR patients,suggesting that high-APR patients had significantly worse recurrence-free survival(P=0.016).The CNLC stage(HR=2.509,95%CI:1.423-4.422,P=0.001),tumor size(HR=1.725,95%CI:1.119-2.660,P=0.014),and APR(HR=1.619:95%CI:1.037-2.527,P=0.034)were all independent FRS predictors.Hypertension(OR=3.09,95%CI:1.385-6.893,P=0.006),open surgery(OR=4.198,95%CI:1.779-9.907,P=0.001),liver cirrhosis(OR=2.376,95%CI:1.194-4.729,P=0.014),and APR(OR=2.151,95%CI:1.160-3.986,P=0.015)were all independent risk predictors for the postoperative major complications.The AUC for APR,ALP,and PA in predicting the major complications was 0.625(95%CI:0.547-0.702),0.613(95%CI:0.534-0.693),and 0.554(0.474-0.634).Conclusion Preoperative APR could be used to predict prognosis and postoperative major complications of HCC patients after radical tumor resection.