Objective: To establish a new scoring system based on the clinicopathological features of hepatocellular carcinoma (HCC) to predict prognosis of patients who received hepatectomy. Methods: A total of 845 HCC patients who underwent hepatectomy from 1999 to 2010 at Cancer Hospital, Chinese Academy of Medical Sciences were retrospectively analyzed. 21 common clinical factors were selected in this analysis. Among these factors, the cut-off values of alpha-fetoprotein (AFP), alkaline phosphatase (ALP) and intraoperative blood loss were evaluated by using a receiver operating characteristic (ROC) curve analysis.The Kaplan-Meier method and Cox regression model were used to evaluate the independent risk factors associated with the prognosis of HCC patients after hepatectomy. HCC postoperatively prognostic scoring system was established according to the minimum weighted method of these independent risk factors, and divided the patients into 3 risk groups, including low-risk, intermediate-risk and high-risk group. The relapse-free survival (RFS) and overall survival (OS) were compared among these groups. Results: The univariate analysis showed that clinical symptoms, preoperative α-fetoprotein (AFP) level, serum alkaline phosphatase (ALP) level, tumor size, tumor number, abdominal lymph node metastasis, macrovascular invasion or tumor thrombus, extrahepatic invasion or serosa perforation, the severity of hepatic cirrhosis, intraoperative blood loss, the liver operative method, pathological tumor thrombus, intraoperative blood transfusion, perioperative blood transfusion were significantly associated with median RFS of these HCC patients (P<0.05). Alternatively, clinical symptoms, preoperative AFP level, serum ALP level, tumor size, tumor number, abdominal lymph node metastasis, macrovascular invasion or tumor thrombus, extrahepatic invasion or serosa perforation, the severity of hepatic cirrhosis, intraoperative blood loss, the liver operative method, pathological lymphocyte invasion, pathological tumor thrombus, intraoperative blood transfusion, perioperative blood transfusion were significantly associated with the median OS of these HCC patients (P<0.05). The multivariate analysis showed that AFP ≥20 ng/ml, clinical symptoms, tumor diameter ≥5 cm, multiple tumors, macrovascular invasion or tumor thrombus, extrahepatic invasion or serosa perforation, moderate and severe liver cirrhosis, non- anatomic resection were the independent risk factors of RFS and OS (P<0.05). The independent risk factor of RFS was intraoperative bleeding loss ≥325 ml (P<0.05); The independent risk factors of OS were abdominal lymph node metastasis and pathological tumors thrombus (P<0.05). The respective weight of 11 independent factors was used to establish the scoring system (scores range from 0 to 26). In the score system, 0 to 5 points were defined as the low-risk group (286 cases), 6 to 12 points were determined as the intermediate-risk group (503 cases), more than 13 points were classified as the high-risk group (56 cases). The median RFS of the low-risk, intermediate-risk and high-risk group were 80, 27 and 6 months, respectively. The differences were statistically significant (P<0.001). The median OS of the three groups were 134, 51 and 15 months, respectively, and the differences were statistically significant (P<0.001). Conclusion: This new score system provides effective prediction of postoperative prognosis for HCC patients.
目的： 建立一个基于肝细胞癌(HCC)临床病理特征的术后预后评分系统。 方法： 回顾性分析1999—2010年中国医学科学院肿瘤医院连续收治的接受肝切除术治疗的845例HCC患者的临床资料，选取临床上常用的21个临床指标进行研究，采用受试者工作特征曲线(ROC)确定术前甲胎蛋白(AFP)水平、术前血清碱性磷酸酶(ALP)水平和术中出血量3个临床指标的截断值(cut－off值)，以Kaplan－Meier法和Cox回归模型确定HCC术后预后的独立危险因素。以最小加权法建立HCC术后预后评分系统，并按评分结果将HCC患者分为低危、中危和高危3个风险组，比较3组HCC患者的复发和生存情况。 结果： 单因素分析显示，HCC患者的中位无复发生存时间(RFS)与患者有无症状、术前AFP水平、血清ALP水平、肿瘤直径、是否多发、腹腔淋巴结转移情况、有无大血管侵犯或存在瘤栓、有无肝外侵犯或穿破浆膜、肝硬化程度、术中出血量、切除方式、是否有病理脉管瘤栓、术中是否输血、有无围手术期输血有关(均P<0.05)；HCC患者的中位总生存时间(OS)与患者有无症状、术前AFP水平、血清ALP水平、肿瘤直径、是否多发、腹腔淋巴结转移情况、有无大血管侵犯或存在瘤栓、有无肝外侵犯或穿破浆膜、肝硬化程度、术中出血量、切除方式、是否有病理淋巴细胞浸润、是否有病理脉管瘤栓、术中是否输血、有无围手术期输血有关(均P<0.05)。多因素分析显示，术前AFP≥20 ng/ml、有临床症状、肿瘤直径≥5 cm、肿瘤多发、大血管侵犯或存在瘤栓、肝外侵犯或穿破浆膜、中度及重度肝硬化、非解剖性切除是影响HCC患者术后RFS和OS的独立危险因素(均P<0.05)。术中出血量≥325 ml是影响患者术后RFS的独立危险因素(P<0.05)，腹腔淋巴结转移和病理脉管瘤栓是影响患者术后OS的独立危险因素(均P<0.05)。将11个预后因素按照各自权重建立HCC术后预后评分系统，评分区间为0～26分，其中0～5分为低危组(286例)，6～12分为中危组(503例)，≥13分为高危组(56例)。低危、中危和高危组患者的中位RFS分别为80、27和6个月，差异有统计学意义(P<0.001)；中位OS分别为134、51和15个月，差异有统计学意义(P<0.001)。 结论： 建立的新型的评分系统对HCC术后的长期生存具有有效的预测意义。.
Keywords: Hepatectomy; Liver neoplasms; Prognosis; Prognostic score system.