第七课：肝癌预后危险因素

clinicopathological factors Age≤65>65SexMFPresentationSubclinicalSymptomaticHepatitis B surface antigenPositiveNegativeHepatitis C antibodyPositiveNegativeDual infectionPositiveNegativeChild classificationGrade AGrade BPreoperative ICG R-15 min (%)≤15>15Serum Urea nitrogen (mg/dl)≤21>21Serum Creatinine (mg/dl)≤1.4>1.4Serum Albumin (g/dl)≤3.5>3.5Serum Alkaline phosphatase (U/L)≤94>94Serum Aspartate aminotransferase (U/L)≤34>34Serum Alanine aminotransferase (U/L)≤36Serum Total bilirubin (mg/dl)≤2.0>2.0Platelet count (≤109/L)≤150>150Prothrombin time/prolong (s)≤4.0>4.0Extent of resection（Type of resection）Major hepatectomyMinor hepatectomyMajor resection is defined as resection of ≥three segments, minor resection as resection of ≤two segments.Blood loss (L)≤4>4Blood transfusionNoYesMorbidityNoYesAFP≤20>20RuptureNoYesTumor size (cm)≤2？5？>2？5？Satellite lesionsNoneYesResection margin (cm)≤1>1Capsular formationPositiveNegativeCapsular invasionNoVascular invasionNoYesDiploidy statusYesNoTumor numberSolitaryMultipleMacroscopic resection margin≤1 cm＞1 cmMicroscopic resection marginPositiveNegativeMicroscopic venous invasionNoYesTumor encapsulationNoYespTNM stage≈IIIIIIAIVAAbbreviation: 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: 2presence 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) levelsHBsAg positive 32 (14.3%) 16% 77% NSHBsAg negative 192 (85.7%) 37% 51%HCV positive 129 (57.6%) 45% 59% NSHCV negative 36 (16.1%) 14% 48%Alpha-fetoprotein _20 ng/mL 110 (49%) 27% 45% NSAlpha-fetoprotein _20 ng/mL 114 (51%) 44% 61%Child A 185 (82.6%) 36% 59% NSChild B _ C 39 (17.4%) 30% 36%Single nodule 200 (89.1%) 32% 52% _.01Multiple nodule 24 (10.9%) 67% 100%Tumor diameter _5 cm 181 (81%) 33% 56% NSTumor diameter _5 cm 43 (19%) 39% 39%Intraop. blood transfusion 71 (31.7%) 42% 58% NSNo intraop. blood transfusion 153 (68.3%) 31% 52%Presence of tumor capsule 81 (36%) 20% 50% _.05Absence of tumor capsule 143 (64%) 43% 60%Microvascular portal invasion 105 (46.9%) 44% 61% _.05No microvascular portal invasion 119 (53.1%) 24% 50%Preop. TACE 98 (43.8%) 37.4% 60.5% NSNo preop. TACE 126 (56.2%) 36.7% 56.7%Wedge resection 67 (29.9%) 33.1% 53.2% NSSegmentectomy (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% _.001AST _80 U/L 67 (29.9%) 60% 74%ALT _80 U/L 131 (58.5%) 26% 50% NSALT _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, preoperativechemoembolization, 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 veinTable 2 Risk factors for hepatic failure after resection of hepatocellular carcinomaTable 3 Risk factors for hepatic failure after resection of hepatocellular carcinomaPPV: 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 Wiley1997.2. 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.。