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肝切除术和肝移植术治疗的肝细胞癌患者3年随访结局比较
DOI: 10.3969/j.issn.1001-5256.2021.02.019
利益冲突声明：本研究不存在研究者、伦理委员会成员、受试者监护人以及与公开研究成果有关的利益冲突，特此声明。
作者贡献声明：平春霞负责课题设计、资料分析、撰写论文；张静、赵伟、马良、房达参与收集数据、修改论文；崔石昌负责拟定写作思路、指导撰写文章并最后定稿。
Three-year follow-up outcomes of hepatocellular carcinoma patients undergoing liver resection versus liver transplantation
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摘要:
目的 比较肝切除术(LR)和肝移植术(LT)两种方法治疗的肝细胞癌(HCC)患者3年的随访结局。 方法 回顾性分析2009年3月—2014年3月于首都医科大学附属北京佑安医院接受手术治疗的171例HCC患者临床资料，根据治疗方法分为LR组(n=83)和LT组(n=88)，比较两组患者的临床资料差异。分类资料组间比较使用χ2检验。采用Kaplan-Meier生存曲线和log-rank检验分析两组之间无瘤生存期和总生存期的差异；用Cox比例风险模型分别对无瘤生存期和总生存期进行单因素和多因素分析。 结果 与LR组对比，LT组的单发肿瘤比例(45.78% vs 85.23%)、直径<3 cm的肿瘤比例(15.66% vs 67.05%)、高Child-Pugh分期比例(9.64% vs 26.14%)明显偏高，LT组的肿瘤复发率明显偏低(48.19% vs 32.95%)，且差异具有统计学意义(χ2值分别为29.649、46.383、7.833、4.121，P值分别为<0.001、<0.001、0.005、0.042)；LR治疗患者的无瘤生存率是46.02%，而LT治疗患者的无瘤生存率为80.71%，两者比较具有统计学差异(P=0.006)；LR治疗患者的总生存率是76.44%，而LT治疗患者的总生存率为86.99%，差异无统计学意义(P=0.219)；Cox单因素和多因素分析均显示治疗方法是无瘤生存期的独立危险因素[RR(95% CI)分别为3.383(1.334~8.579)、0.239(0.093~0.612), P值均<0.05]，而治疗方法对于总生存期的预测未达到统计学差异(P=0.232)。 结论 LT更倾向于选择肝功能储备较差的早期肝癌患者，3年无瘤生存率较好。 Abstract:Objective To investigate the three-year follow-up outcomes of hepatocellular carcinoma patients undergoing liver resection (LR) versus liver transplantation (LT). Methods A retrospective analysis was performed for 171 patients with hepatocellular carcinoma who underwent surgical treatment in Beijing YouAn Hospital, Capital Medical University, from March 2009 to March 2014, and according to the treatment method, they were divided into LR group(n=83) and LT group(n=88). Related clinical data were compared between the two groups. The chi-square test was used for comparison of categorical data between two groups; the Kaplan-Meier survival curve and the log-rank test were used for comparison of disease-free survival and overall survival between two groups, and the Cox proportional hazards model was used for the univariate and multivariate analyses of disease-free survival and overall survival. Results Compared with the LR group, the LT group had a significantly higher proportion of patients with single tumor [45.78% (38/83) vs 85.23% (75/88), χ2=29.649, P < 0.001], tumor size < 3 cm [15.66% (13/83) vs 67.05% (59/88), χ2=46.383, P < 0.001], or high Child-Pugh class [9.64% (8/83) vs 26.14% (23/88), χ2=7.833, P=0.005] and a significantly lower recurrence rate of tumor [48.19%(40/83) vs 32.95%(29/88), χ2=4.121, P=0.042]. There was a significant difference in disease-free survival rate between the LR group and the LT group (46.02% vs 80.71%, P=0.006); the LT group had a higher overall survival rate than the LR group (86.99% vs 76.44%, P=0.219). Both univariate and multivariate analyses showed that treatment method was an independent risk factor for disease-free survival (risk ratio [RR] =3.383, 95% confidence interval[CI]: 1.334-8.579;RR=0.239, 95%CI:0.093-0.612, both P < 0.05), but the prediction of overall survival by treatment method did not reach statistical significance(P=0.232). Conclusion LT is recommended for patients with early-stage hepatocellular carcinoma and can achieve a satisfactory three-year disease-free survival rate. -
Key words:
- Carcinoma, Hepatocellular /
- Hepatectomy /
- Liver Transplantation /
- Follow-Up Studies
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表 1 肝癌患者的基本资料
指标 例数(n=171) 手术类型 χ2值 P值 LR组(n=83) LT组(n=88) 性别(例) 0.192 0.661 男 142 70 72 女 29 13 16 年龄(例) 0.117 0.732 ≤50岁 95 45 50 >50岁 76 38 38 潜在肝病(例) 2.333 0.311 HBV 153 76 77 HCV 17 6 11 其他 1 1 0 肿瘤位置(例) 1.161 0.281 右叶 119 61 58 非右叶或多叶 52 22 30 肿瘤数目(例) 29.649 <0.001 单发 113 38 75 多发 58 45 13 肿瘤大小(例) 46.383 <0.001 <3 cm 72 13 59 3~5 cm 62 43 19 >5 cm 37 27 10 AFP (例) 3.350 0.187 <20 ng/ml 82 42 40 20~400 ng/ml 52 20 32 >400 ng/ml 37 21 16 TNM分期(例) 0.174 0.677 Ⅰ+Ⅱ 117 57 63 Ⅲ+Ⅳ 54 26 25 BCLC肝癌分期(例) 0.057 0.972 A 87 42 45 B 44 22 22 C 40 19 21 Child-Pugh分级(例) 7.833 0.005 C 140 75 65 B+C 31 8 23 病理分级(例) 2.573 0.276 低分化 29 18 11 中分化 113 52 61 高分化 29 13 16 肿瘤复发(例) 4.121 0.042 否 102 43 59 是 69 40 29 HCC所致死亡(例) 0.937 0.333 否 139 65 74 是 32 18 14 
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表 2 肝癌患者无瘤生存期和总生存期的单因素分析
指标 无瘤生存期 总生存期 RR 95%CI P值 RR 95%CI P值 性别 男 1.000 1.000 女 0.539 0.213~1.367 0.193 0.474 0.110~2.034 0.315 年龄 ≤50岁 1.000 1.000 >50岁 1.023 0.570~1.838 0.939 0.678 0.281~1.636 0.387 肝病 HBV 1.000 1.000 HCV/其他 0.380 0.092~1.569 0.181 0.872 0.203~3.747 0.854 肿瘤位置 肝右叶 1.000 1.000 其他位置 0.816 0.422~1.581 0.548 0.693 0.254~1.893 0.475 肿瘤数目 单发 1.000 1.000 多发 1.513 0.833~2.751 0.174 1.491 0.628~3.542 0.365 肿瘤大小 <3 cm 1.000 1.000 <3 cm 1.000 1.000 3~5 cm 1.360 0.647~2.860 0.418 2.956 0.890~9.819 0.077 >5 cm 3.877 1.924~7.812 <0.001 5.595 1.721~18.189 0.004 AFP <20 ng/ml 1.000 1.000 20~400 ng/ml 1.862 0.861~4.025 0.114 0.982 1.699~12.123 0.003 >400 ng/ml 3.625 1.804~7.285 <0.001 4.539 1.699~12.123 0.003 TNM分期 Ⅰ-Ⅱ 1.000 1.000 Ⅲ 4.084 2.237~7.455 <0.001 4.985 2.058~12.076 <0.001 BCLC HCC分期 A 1.000 1.000 B 1.778 0.887~3.564 0.003 1.235 0.349~4.378 0.001 C 3.008 1.453~6.230 0.105 0.003 5.566 2.052~15.101 0.001 Child-Pugh分级 A 1.000 1.000 B+C 0.446 0.160~1.245 0.123 1.886 0.731~4.864 0.189 病理分期 低分化 1.000 1.000 中/高分化 0.813 0.378~1.750 0.597 0.524 0.203~1.350 0.181 治疗方法 LR 1.000 1.000 LT 3.383 1.334~8.579 0.010 0.474 0.140~1.610 0.232
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