肝硬化肝癌患者手术切除预后影响因素的回顾性研究

刘辉; 张曦; 肖森林; 毕华强; 李晓武

doi:10.16016/j.1000-5404.201706022

您当前的位置：

首页 >

文章列表页 >

肝硬化肝癌患者手术切除预后影响因素的回顾性研究

临床医学 | 更新时间：2026-01-09

- 肝硬化肝癌患者手术切除预后影响因素的回顾性研究
- Prognosis of hepatocellular carcinoma patients with liver cirrhosis after hepatectomy: a retrospective study
- 第三军医大学学报 2017年39卷第20期页码：2022-2029
- 作者机构：
  
  400038 重庆, 第三军医大学西南医院肝胆外科
- 作者简介：
  
  [李晓武, 电话: (023)68773077, E-mail: lixw1966@163.com LI Xiaowu, E-mail:lixw1966@163.com
- 基金信息：
  
  国家自然科学基金重点项目(81430063)
- DOI：10.16016/j.1000-5404.201706022
  中图分类号： R181.32;R730.56;R735.7
- 收稿：2017-06-04，
  
  修回：2017-07-10，
  
  纸质出版：2017-10-30
- 稿件说明：
移动端阅览
刘辉, 张曦, 肖森林, 等. 肝硬化肝癌患者手术切除预后影响因素的回顾性研究[J]. 第三军医大学学报, 2017,39(20):2022-2029.

Hui LIU, Xi ZHANG, Senlin XIAO, et al. Prognosis of hepatocellular carcinoma patients with liver cirrhosis after hepatectomy: a retrospective study[J]. Journal of Third Military Medical University, 2017, 39(20): 2022-2029.
刘辉, 张曦, 肖森林, 等. 肝硬化肝癌患者手术切除预后影响因素的回顾性研究[J]. 第三军医大学学报, 2017,39(20):2022-2029. DOI： 10.16016/j.1000-5404.201706022.

Hui LIU, Xi ZHANG, Senlin XIAO, et al. Prognosis of hepatocellular carcinoma patients with liver cirrhosis after hepatectomy: a retrospective study[J]. Journal of Third Military Medical University, 2017, 39(20): 2022-2029. DOI： 10.16016/j.1000-5404.201706022.

摘要

目的

探讨合并肝硬化的不同大小肝癌患者临床资料特点及肝切除术近远期预后的影响因素。

方法

回顾性分析第三军医大学西南医院2008-2012年期间因肝癌而接受肝脏切除手术且具有肝硬化的连续患者资料共703例。收集患者临床病理资料并进行随访。对可能影响近、远期预后的因素分别进行Logistic及Cox回归分析。

结果

703例患者中，男性638例，女性65例。其中，肿瘤最大直径＜5 cm的患者(小肝癌组，ST组)280例(39.8%)，肿瘤最大直径≥5 cm的患者(大肝癌组，LT组)423例(60.2%)。与ST组患者比较，LT组患者术前甲胎蛋白、天门冬氨酸氨基转移酶(AST)及脉管癌栓发生率较高，但白蛋白及血小板较低。术中资料表明LT组患者复杂手术比例、术中失血量、肝门阻断时间及手术时间都较高。而LT组患者术后并发症的总发生率也较高(35.0%

27.1%

=0.029)。多因素分析显示，在ST组中，复杂手术(

: 2.755

95%

: 1.196~6.344

=0.017) 是独立的危险因素，而白蛋白水平低于35 g/L(

: 4.049

95%

: 2.105~7.752

0.01) 与手术时间

240 min(

: 3.044

95%

: 1.912~4.847

0.01) 是LT组独立的危险因素。远期预后分析显示：LT组患者无瘤生存时间(progression-free survival，PFS)和总生存时间(overall-survival，OS)均比ST组短(

0.01)。多因素分析显示，在ST组中，癌栓是影响PFS的独立危险因素；而Child-Pugh B级、癌栓和复杂手术是影响OS的独立危险因素。在LT组中，癌栓和手术时间＞240 min均为影响PFS的独立危险因素；而AST＞40 U/L和癌栓是影响OS的独立危险因素。

结论

直径＜5 cm的小肝癌较之直径≥5 cm的大肝癌患者有着更高的近、远期生存率。而选择无癌栓的大肝癌病例，改善术前白蛋白、转氨酶水平，提高手术熟练度及合理使用手术器械[如射频消融辅助(radiofrequency ablation assist

RFA)]以缩短手术时间，可以降低术后并发症并改善大肝癌手术治疗的预后。

Abstract

Objective

To investigate the clinical characteristics of hepatocellular carcinoma (HCC) patients with liver cirrhosis and the prognostic factors influencing the short-and long-term outcomes after hepatectomy.

Methods

We retrospectively analyzed 703 HCC patients with liver cirrhosis who underwent hepatectomy from January 2008 to December 2012 in our hospital. Among the 703 patients

638 were males (90.8%) and 65 were females (9.2%). The patients were divided into 2 groups based on the tumor size: small tumor (ST) group (diameter

5 cm

=280

39.8%) and large tumor (LT) group (diameter ≥5 cm

=423

60.2%). The potential prognostic factors affecting the short-and long-term outcomes were analyzed using univariate and multivariate logistic and Cox regression analyses.

Results

Compared with the ST group

the LT group had higher alpha-fetoprotein (AFP) and aspartate aminotransferase (AST) levels with increased incidence of tumor embolization

but lower albumin and platelet levels pre-operatiuely. Intraoperative data showed that the LT group had larger proportion of patient with complex surgery

more intraoperative blood loss

longer hepatic hilar obstruction and operation time. Moreover

the overall incidence of postoperative complications was significantly higher in the LT group than the ST group (35.0%

27.1%

=0.029). The multivariate logistic regression analysis showed that the surgery complexity (

=2.755

95%

:1.196~ 6.344

=0.017) was an independent risk factor for the development of postoperative complications in the ST group

while albumin level

35 g/L(

=4.049

95%

: 2.105~7.752

0.01) and operation time

240 min (

=3.044

95%

: 1.912~4.847

0.01) were the factors for the LT group. Postoperative long-term outcome showed that progression-free survival (PFS) and overall survival (OS) were shorter in the LT group than the ST group (

=0.001). The multivariate Cox regression analysis demonstrated that tumor embolization was an independent risk factor influencing PFS in both groups

and operation time

240 min was exclusive in the LT group. Additionally

the independent risk factors influencing OS in the ST group were Child-Pugh class B

tumor embolization and operation time

240 min

whereas in the LT groups the factors were AST

40 IU/l and tumor embolization.

Conclusion

HCC patients with tumors < 5 cm have better short-and long-term outcomes than those with tumors ≥5 cm. For LT group patients without tumor embolization

increasing preoperative albumin and transaminase levels

advancing surgical proficiency and rational use of instruments (such as radiofrequency ablation assist

RFA) to shorten the operation time

can not only reduce postoperative complications

but also improve the long-term outcomes.

关键词

Keywords

references

TORRE L A, BRAY F, SIEGEL R L, et al. Global cancer statistics, 2012[J]. CA Cancer J Clin, 2015, 65(2): 87-108. DOI: 10.3322/caac.21262.

EL-SERAG H B. Hepatocellular carcinoma[J]. N Engl J Med, 2011, 365(12): 1118-1127. DOI: 10.1056/NEJMra1001683.

YAU T, TANG V Y, YAO T J, et al. Development of Hong Kong Liver Cancer staging system with treatment stratification for patients with hepatocellular carcinoma[J]. Gastroenterology, 2014, 146(7): 1691-1700. DOI: 10.1053/j.gastro.2014.02.032.

VAUTHEY J N, LAUWERS G Y, ESNAOLA NF, et al. Simplified staging for hepatocellular carcinoma[J]. J Clin Oncol, 2002, 20(6): 1527-1536. DOI: 10.1200/JCO.2002.20.6.1527.

LLOVET J M, BRú C, BRUIX J. Prognosis of hepatocellular carcinoma: the BCLC staging classification[J]. Semin Liver Dis, 1999, 19(3): 329-338. DOI: 10.1055/s-2007-1007122.

EDGE S B, COMPTON C C. The American Joint Committee on Cancer: the 7th edition of the AJCC cancer staging manual and the future of TNM[J]. Ann Surg Oncol, 2010, 17(6): 1471-1474. DOI: 10.1245/s10434-010-0985-4.

杨秉辉, 夏景林.原发性肝癌的临床诊断与分期标准[J].中华肝脏病杂志, 2001, 9(6): 324.

YANG B H, XIA J L. Clinical diagnosis and staging criteria of primary liver cancer[J]. Chin J Hepatol, 2001, 9(6): 324.

ANDREOU A, VAUTHEY J N, CHERQUI D, et al. Improved long-term survival after major resection for hepatocellular carcinoma: a multicenter analysis based on a new definition of major hepatectomy[J]. J Gastrointest Surg, 2013, 17(1): 66-77. DOI: 10.1007/s11605-012-2005-4.

POON R T P, FAN S T. Hepatectomy for hepatocellular carcinoma: Patient selection and postoperative outcome[J]. Liver Transplantation, 2004, 10(S2): S39-S45. DOI: 10.1002/lt.20040.

KIM S J, LEE K K, KIM D G. Tumor size predicts the biological behavior and influence of operative modalities in hepatocellular carcinoma[J]. Hepatogastroenterology, 2010, 57(97): 121-126.

EGUCHI S, TAKATSUKI M, HIDAKA M, et al. Predictor for Histological Microvascular Invasion of Hepatocellular Carcinoma: A Lesson from 229 Consecutive Cases of Curative Liver Resection[J]. World Journal of Surgery, 2010, 34(5): 1034-1038. DOI: 10.1007/s00268-010-0424-5.

HIROKAWA F, HAYASHI M, MIYAMOTO Y, et al. Predictors of poor prognosis by recurrence patterns after curative hepatectomy for hepatocellular carcinoma in Child-Pugh classification A[J]. Hepatogastroenterology, 2015, 62(137): 164-168.

GOH B K, TEO J Y, CHAN C Y, et al. Importance of tumor size as a prognostic factor after partial liver resection for solitary hepatocellular carcinoma: Implications on the current AJCC staging system[J]. J Surg Oncol, 2016, 113(1): 89-93. DOI: 10.1002/jso.24099.

HO C M, HU R H, LEE P H, et al. Long-term survival in patients with T2 hepatocellular carcinoma after primary curative resection can be further stratified by tumor size[J]. Medicine (Baltimore), 2014, 93(27): e203. DOI: 10.1097/MD.0000000000000203.

GOH B K, CHOW P K, TEO J Y, et al. Number of nodules, Child-Pugh status, margin positivity, and microvascular invasion, but not tumor size, are prognostic factors of survival after liver resection for multifocal hepatocellular carcinoma[J]. J Gastrointest Surg, 2014, 18(8): 1477-1485. DOI: 10.1007/s11605-014-2542-0.

ETTORRE G M, LEVI SANDRI G B, COLASANTI M, et al. Liver resection for hepatocellular carcinoma ≥5 cm[J]. Transl Gastroenterol Hepatol, 2017, 2: 22. DOI: 10.21037/tgh.2017.03.13.

KOBAYASHI T, ITAMOTO T, TASHIRO H, et al. Tumor-related factors do not influence the prognosis of solitary hepatocellular carcinoma after partial hepatectomy[J]. J Hepatobiliary Pancreat Sci, 2011, 18(5): 689-699. DOI: 10.1007/s00534-011-0379-4.

吴力群, 邱法波, 张顺, 等.原发性肝细胞癌R0切除标准的探讨[J].中国实用外科杂志, 2011, 31(11): 1027-1030.

WU L Q, QIU F B, ZHANG S, et al. Estimate of the criterion for R0 resection in primary hepatocellular carcinoma[J].Chin J Prac Surg, 2011, 31(11): 1027-1030.

CLAVIEN P A, BARKUN J, de Oliveira M L, et al. The Clavien-Dindo classification of surgical complications: five-year experience[J]. Ann Surg, 2009, 250(2): 187-196. DOI: 10.1097/SLA.0b013e3181b13ca2.

TORZILLI G, DONADON M, Marconi M, et al. Hepatectomy for stage B and stage C hepatocellular carcinoma in the Barcelona Clinic LiverCancer classification: results of a prospective analysis[J]. Arch Surg, 2008, 143(11): 1082-1090. DOI:10.1001/archsurg.143.11.1082.

[YIN L, LI H, LI A J, et al. Partial hepatectomy vs. transcatheter arterial chemoembolization for resectable multiple hepatocellular carcinoma beyond Milan criteria: A RCT[J ] . Journal of Hepatology, 2014, 61(1): 82-88. DOI: 10.1016/j.jhep.2014.03.012. http://dx.doi.org/10.1016/j.jhep.2014.03.012

DE LOPE C R, TREMOSINI S, FORNER A, et al. Management of HCC[J]. J Hepatol, 2012, 56(Suppl 1): S75-S87. DOI: 10.1016/S0168-8278(12)60009-9.

European Association For The Study Of The L, European Organisation For R, Treatment Of C. EASL-EORTC clinical practice guidelines: management of hepatocellular carcinoma[J]. J Hepatol, 2012, 56(4): 908-943. DOI: 10.1016/j.jhep.2011.12.001.

JARNAGIN W R, GONEN M, FONG Y, et al. Improvement in perioperative outcome after hepatic resection: analysis of 1, 803 consecutive cases over the past decade[J]. Ann Surg, 2002, 236(4): 397-406; discussion 406-7. DOI: 10.1097/01.SLA.0000029003.66466.B3.

VIRANI S, MICHAELSON J S, HUTTER M M, et al. Morbidity and mortality after liver resection: results of the patient safety in surgery study[J]. J Am Coll Surg, 2007, 204(6): 1284-1292. DOI: 10.1016/j.jamcollsurg.2007.02.067.

薛峰, 沈锋, 奚韬.肝癌切除病人门静脉癌栓的分布状况[J].外科理论与实践, 2004, 9(4): 278-281. DOI: 10.3969/j.issn.1007-9610.2004.04.006.

XUE F, SHEN F, XI T. The distribution of portal vein tumor thrombus in patients with primary liver carcinoma[J]. J Sur Concep Prac, 2004, (04): 278-281. 2004, (04): 278-281. DOI: 10.3969/j.issn.1007-9610.2004.04.006

MERCADO M A, CHAN C, OROZCO H, et al. Long-term evaluation of biliary reconstruction after partial resection of segments Ⅳ and Ⅴ in iatrogenic injuries[J]. J Gastrointest Surg, 2006, 10(1): 77-82. DOI: 10.1016/j.gassur.2005.07.003.

NANASHIMA A, Abo T, TAKESHITA H, et al. Safety of hepatectomy accompanying combined resection of other organs[J]. Hepatogastroenterology, 2012, 59(118): 1915-1920. DOI: 10.5754/hge11812.

ZHANG X Y, LI C, WEN T F, et al. Synchronous splenectomy and hepatectomy for patients with hepatocellular carcinoma and hypersplenism: A case-control study[J]. World J Gastroenterol, 2015, 21(8): 2358-2366. DOI: 10.3748/wjg.v21.i8.2358.

GUO R, FENG X, XIAO S, et al. Short-and long-term outcomes of hepatectomy with or without radiofrequency-assist for the treatment of hepatocellular carcinomas: a retrospective comparative cohort study[J]. Biosci Trends, 2015, 9(1): 65-72. DOI: 10.5582/bst.2014.01142.

WEBER J C, NAVARRA G, JIAO L R, et al. New Technique for Liver Resection Using Heat Coagulative Necrosis[J]. Annals of Surgery, 2002, 236(5): 560-563. DOI: 10.1097/00000658-200211000-00004.

KUDO M, IZUMI N, SAKAMOTO M, et al. Survival Analysis over 28 Years of 173, 378 Patients with Hepatocellular Carcinoma in Japan[J]. Liver Cancer, 2016, 5(3): 190-197. DOI: 10.1159/000367775.

LIU X Y, XU J F. Liver resection for young patients with large hepatocellular carcinoma: a single center experience from China[J]. World Journal of Surgical Oncology, 2014, 12(1): 175. DOI: 10.1186/1477-7819-12-175.

浏览量

下载量

CSCD

文章被引用时，请邮件提醒。

提交

工具集

关联资源

急性前循环大血管闭塞性卒中患者血管内治疗后发生卒中相关性肺炎的危险因素分析

核仁磷酸蛋白1突变的分子异质性对急性髓系白血病预后的影响

非肌层浸润性膀胱癌二次电切术后疗效评估及预后影响因素分析

Stanford A型主动脉夹层术后急性肾功能损伤的发生情况及其危险因素分析

胚胎着床位置对前置胎盘的预测价值及相关影响因素分析