第七课：肝癌预后危险因素

clinicopathological factors Age

≤65

>65

Sex

M

F

Presentation

Subclinical

Symptomatic

Hepatitis B surface antigen

Positive

Negative

Hepatitis C antibody

Positive

Negative

Dual infection

Positive

Negative

Child classification

Grade A

Grade B

Preoperative ICG R-15 min (%)

≤15

>15

Serum Urea nitrogen (mg/dl)

≤21

>21

Serum Creatinine (mg/dl)

≤1.4

>1.4

Serum Albumin (g/dl)

≤3.5

>3.5

Serum Alkaline phosphatase (U/L)

≤94

>94

Serum Aspartate aminotransferase (U/L)

≤34

>34

Serum Alanine aminotransferase (U/L)

≤36

Serum Total bilirubin (mg/dl)

≤2.0

>2.0

Platelet count (≤109/L)

≤150

>150

Prothrombin time/prolong (s)

≤4.0

>4.0

Extent of resection（Type of resection）

Major hepatectomy

Minor hepatectomy

Major resection is defined as resection of ≥three segments, minor resection as resection of ≤two segments.

Blood loss (L)

≤4

>4

Blood transfusion

No

Yes

Morbidity

No

Yes

AFP

≤20

>20

Rupture

No

Yes

Tumor size (cm)

≤2？5？

>2？5？

Satellite lesions

None

Yes

Resection margin (cm)

≤1

>1

Capsular formation

Positive

Negative

Capsular invasion

No

Vascular invasion

No

Yes

Diploidy status

Yes

No

Tumor number

Solitary

Multiple

Macroscopic resection margin

≤1 cm

＞1 cm

Microscopic resection margin

Positive

Negative

Microscopic venous invasion

No

Yes

Tumor encapsulation

No

Yes

pTNM stage≈

I

II

IIIA

IVA

Abbreviation: pTNM stage, pathologic tumor-node-metastasis stage. 1

对于乙肝患者而言，术前HBV-DNA水平的影响很重要！

此外，肝硬化、肝纤维化程度的影响！

The following clinicopathologic variables that might correlate with disease-free survival and recurrence rates were evaluated: 2

presence of HBsAg marker,

presence of anti-HCV antibodies,

Child classification,

[alpha]-fetoprotein level,

diameter of nodules (<5 cm vs. >5 cm),

number of nodules (single vs. multiple),

preoperative intra-arterial chemoembolization,

type of resection,

intraoperative blood transfusion,

micro- or macroscopic portal vein infiltration,

presence of tumor capsule,

preoperative aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels

HBsAg positive 32 (14.3%) 16% 77% NS

HBsAg negative 192 (85.7%) 37% 51%

HCV positive 129 (57.6%) 45% 59% NS

HCV negative 36 (16.1%) 14% 48%

Alpha-fetoprotein _20 ng/mL 110 (49%) 27% 45% NS

Alpha-fetoprotein _20 ng/mL 114 (51%) 44% 61%

Child A 185 (82.6%) 36% 59% NS

Child B _ C 39 (17.4%) 30% 36%

Single nodule 200 (89.1%) 32% 52% _.01

Multiple nodule 24 (10.9%) 67% 100%

Tumor diameter _5 cm 181 (81%) 33% 56% NS

Tumor diameter _5 cm 43 (19%) 39% 39%

Intraop. blood transfusion 71 (31.7%) 42% 58% NS

No intraop. blood transfusion 153 (68.3%) 31% 52%

Presence of tumor capsule 81 (36%) 20% 50% _.05

Absence of tumor capsule 143 (64%) 43% 60%

Microvascular portal invasion 105 (46.9%) 44% 61% _.05

No microvascular portal invasion 119 (53.1%) 24% 50%

Preop. TACE 98 (43.8%) 37.4% 60.5% NS

No preop. TACE 126 (56.2%) 36.7% 56.7%

Wedge resection 67 (29.9%) 33.1% 53.2% NS

Segmentectomy (1–2 segments) 135 (60.3%) 35% 55.2%

Hepatectomy (_2 segments) 22 (9.8%) 33.4% 56.3%

AST _80 U/L 157 (70.1%) 24% 46% _.001

AST _80 U/L 67 (29.9%) 60% 74%

ALT _80 U/L 131 (58.5%) 26% 50% NS

ALT _80 U/L 93 (41.5%) 46% 61%

In the present series, disease-free survival was significantly longer in patients with single nodules, complete tumor capsule, no portal vein infiltration, and low aminotransferase levels.

The following were analyzed: twelve clinical factors (sex, age ≤ or ＞60 years, subclinical or symptomatic presentation, Child’s grade A or B, serum bilirubin level ≤ or ＞20 mmol/L, serum albumin level ≤ or ＞35 g/L, platelet count ≤or ＞100×109 platelets/L, prothrombin time ≤ or . 12.5 seconds, serum AST level ≤ or . 100 IU/L, serum ALT level ≤or . 100 IU/L, ICG R-15 ≤or . 14%, and serum alpha-fetoprotein level ≤ or . 20 ng/mL), five operative or treatment factors (major or minor resection, blood loss ≤ or . 1.5 L, perioperative transfusion, preoperative

chemoembolization, and postoperative adjuvant chemotherapy), and six pathologic factors (tumor size ≤ or . 5 cm, solitary or multiple tumors, macroscopic resection margin ≤or . 1 cm, venous invasion, tumor differentiation, and encapsulation) of potential prognostic significance.

indocyanine green retention rate at 15 min; AST: aspartate aminotransferase; ALT: alanine aminotransferase; GSA-Rmax: regional maximum removal rate of technetium-99 m galactosyl human serum albumin; HA: hyaluronic acid; AFP: α-fetoprotein; PIVKA-II: protein-induced vitamin K antagonist-II; TACE: transcatheter arterial chemoembolization; fc: microscopic capsule formation; TW: surgical margin < 5 mm; VP: microscopic invasion of the portal vein; VV: microscopic invasion of the hepatic vein

Table 2 Risk factors for hepatic failure after resection of hepatocellular carcinoma

Table 3 Risk factors for hepatic failure after resection of hepatocellular carcinoma

PPV: positive predictive value; NPV: negative predictive value

参考文献

1. Sobin LH, Wittekind C. TNM Classification of Malignant Tumours (ed 5). New York, NY, John Wiley

1997.

2. Ercolani G, Grazi GL, Ravaioli M, et al. Liver resection for hepatocellular carcinoma on cirrhosis:

univariate and multivariate analysis of risk factors for intrahepatic recurrence. Ann Surg 2003;237(4):536-43.