目的 分析基于术前外周血中性粒细胞与淋巴细胞计数的比值(neutrophil-to-lymphocyte ratio,NLR)联合血小板与淋巴细胞计数的比值(platelet-to-lymphocyte ratio,PLR)的评分方法(NLR-PLR)对接受肝切除术治疗的肝细胞癌(HCC)病人预后的预测能力.方法 回顾性分析上海东方肝胆外科医院454例接受根治性肝切除术的HCC病人临床资料.NLR-PLR评分范围为0-2分,其中NLR＞2.357或PLR ＞8.311均判定为1分,两者均符合计2分,符合一项者为1分,均未达到者为0分.采用Log-rank检验比较术后1年、3年和5年的无瘤生存率(recurrencefreesurvival,RFS),Cox比例风险模型分析影响RFS的危险因素,受试者工作特性曲线下面积(area under curve,AUC)及灵敏度和特异度判断预测的准确性.结果 NLR-PLR评分为0、1和2分者分别为116、131和207例,1年、3年和5年的无瘤生存率分别为86.4％、79.1％和66.5％;67.6％、42.9％和31.4％;60.1％,25.6％和16.9％ (P ＜0.0001).Cox分析提示NLR-PLR评分(风险比:1.782,95％可信区间:1.518～2.093,P＜0.001)是影响无瘤生存时长的独立危险因素.NLR-PLR评分预测5年无瘤生存状态的AUC为0.771,以1分为截断值,预测的灵敏度为0.880、特异度为0.545.结论 采用术前NLR-PLR评分能够准确预测HCC病人接受肝切除术治疗的预后.

目的:探讨不同病因的肝内胆管癌(intrahepatic cholangiocarcinoma,ICC)患者行肝切除术预后与年龄之间的关系.方法:对东方肝胆外科医院2004至2010年期间行R0切除术的606名肝内胆管癌患者进行分析.将患者分为乙肝相关组(HBV-ICC,n=456),结石相关组(stone-ICC,n=75)及其他病因组(other-ICC,n=85).按年龄分为青年组(<40岁)、中年组(40～60岁)及老年组(>60岁).分别对不同年龄段不同病因的患者进行生存分析对比.结果:青年组及老年组两种病因的总生存期差异无统计学意义(P=0.236,P=0.151);而中年组两种病因总生存期差异有统计学意义(P=0.002);青年组及老年组两种病因的复发率差异无统计学意义(P=0.169,P=0.126),而中年组复发率差异有统计学意义(P=0.003).结论:在不同年龄段的患者中,不同病因肝内胆管癌切除术后的生存及复发均存在差异.

肝内胆管癌(intrahepatic cholangiocarcinoma,ICC)约占原发性肝癌的10％ ～ 15％,近年来其发病率在全球范围内呈上升趋势[1].ICC的发病诱因及病因复杂,目前已确定的危险因素有年龄、肝内胆管结石、肝血吸虫病、胆管腺瘤、胆管乳头状瘤病、胆管囊肿和Caroli病[2].近年来,全基因组测序技术发展和ICC基因表达谱的深入研究为ICC的分子靶向治疗提供了新的线索,将有望成为ICC的突破性治疗方法.ICC恶性程度高,发病隐匿,许多病人就诊时已经达到疾病的中晚期,失去根治性手术治疗的机会,加之临床上缺乏有效的肿瘤筛查及诊断标志物,故导致ICC病人诊疗困难,预后极差.根治性手术切除是目前唯一有效的治疗方法,但因术后高复发率导致ICC病人术后5年的生存率在20％ ～40％[1].因此,如何有效地综合治疗ICC成为摆在临床医生面前的一个难题.

Objective To explore the impact of postoperative transarterial chemoembolization(TACE) on the overall survival of hepatocellular carcinoma(HCC) patients combined with portal vein tumor thrombus (PVTT).Methods Clinical and pathological data of 129 consecutive HCC patients with PVTT from February 2003 to October 2010 in our hospital were retrospectively analysed,according to whether they accepted postoperative TACE,they were divided into two groups,namely TACE group(76 cases) and non-TACE group(53 cases).Kaplan-Meier curve compared the recurrence rates of the two groups,and Cox regression model was used to analyze the risk factors of overall survival.129 patients were stratified into two groups according to the different types of PVTT(Vp1/2 and Vp3/4,referring to the criterion of the Liver Cancer Study Group of Japan) to explore the role of TACE on the rates of overall survival.Results The 1-,2-,3-year overall survival rates between the two groups were 66.7％,74.5％,76.8％ vs.71.7％,90.6％,95.3％ (P =0.015).Cox regression analysis showed that the type of PVTT,tumor diameter greater than 5cm,multiple tumor were independent risk factors to overall survival,and postoperative TACE is associated with better overall survival.Stratified analysis showed that postoperative TACE could significantly prolong the survival time of Vp1/2 patients according to the results of K-M curves and Cox regression analysis.Conclusions Postoperative TACE could prolong the overall survival of HCC patients combined with PVTr,especially for those with Vp1/2.

Objective To establish a nomogram model for predicting posthepatectomy liver failure (PHLF) in patients with HBV-related hepatocellular carcinoma (HCC). Methods Clinical data of 628 patients with HBV-related HCC who underwent radical hepatectomy in Eastern Hepatobiliary Surgery Hospital, the Second Military Medical University between January 2010 and December 2010 were retrospectively analyzed. According to the operation time, all patients were divided into the model establishment group (n=471) and validation group (n=157). In the model establishment group, 409 cases were males and 62 females, aged (52±21) years old on average. In the validation group, 135 cases were males and 22 females, aged (52±11) years old on average. The informed consents of all patients were obtained and the local ethical committee approval was received. The independent risk factors of PHLF in the model establishment group were identified by Logistic regression analysis. Based upon the independent risk factors, the nomogram model for predicting PHLF of HCC was established. The accuracy of nomogram model for predicting PHLF was respectively detected in two groups by computer consistency coefficient (C-index) and calibration graph method. Results Multivariate Logistic regression analysis for the model establishment group revealed that, PT>13 s (OR=2.522, 95%CI:1.384-4.596; P 17.1 μmol/L (OR=2.088, 95%CI:1.342-3.251; P 44 U/L (OR=1.710, 95%CI:1.141-2.562; P<0.05), positive HBeAg (OR=1.658, 95%CI: 1.058-2.597; P<0.05), intraoperative blood transfusion (OR=3.407, 95%CI:1.945-5.967; P<0.05) and liver cirrhosis (OR=1.835, 95%CI:1.200-2.805; P<0.05) were the independent risk factors for PHLF. After the establishment of nomogram model, the C-index was respectively 0.727 and 0.719 in the model establishment group and validation group. In the calibration graph, the standard curve was properly fit with the predicting calibration curve, suggesting that the model consistency was fine. Conclusions The nomogram model for predicting PHLF in patients with HBV-related HCC is successfully established. And the model offers certain guiding significance for clinical treatment of HBV-related HCC. Key words: Carcinoma, hepatocellular; Hepatitis B; Liver failure; Nomogram; Risk factors

<正>1前言我国是肝细胞癌(简称肝癌)的高发地,每年新发病例约占全球新发病例的55%[1]。目前学术界公认肝切除术是除肝移植外最有可能根治肝癌的方法,而且随着围手术期处理水平的提高、外科技术的进步,手术死亡率和并发症发生率已大大降低,但术

Objective To analyze the influence of infection with hepatitis B on the recurrence and survival of patients with hepatocellular carcinoma(HCC) who underwent radical resection.Methods Cases in Eastern Hepatobiliary Surgery Hospital between 2005 and 2008 were retrospectively studied.According to the test of HBsAg and hepatitis C,we divided patients into HBs Ag-positive A groups(n=79) and non-hepatitis B group(including non-hepatitis C)(n=79),paired for age,gender,tumor diameter,vascular invasion,and tumor number at a ratio of 1∶1.The characteristics of the clinical and pathological data between the two groups,recurrence and death as the end point,were analyzed combined with the recurrence rate of surgical treatment,survival rate and prognostic risk factors.Results One,3,5 year recurrence and survival rates were 48%,80%,85% and 75%,41%,35% in patients with hepatitis B,respectively;and 27%,65%,76% and 86%,58%,44% in patients with non-hepatitis B,respectively.The recurrence rate in hepatitis B group was higher than that in non-hepatitis B group(P=0.012).The survival time was less in hepatitis B group than in non-hepatitis B group(P=0.010).COX proportional hazards model showed that hepatitis B positive,multiple tumors,vascular invasion,capsular invasion and TNM staging were risk factors related with HCC recurrence;while hepatitis B positive,multiple tumors,intra-operative blood transfusion,vascular invasion,capsular invasion and TNM staging were the risk factors related with HCC survival.Conclusions HCC patients with hepatitis B have a worse prognosis showing higher recurrence rate and shorter survival time.

Objective To elucidate whether the hepatectomy is suitable for HCC with portal hypertension or not. Methods During 1996 to 2001,a total of 626 cases underwent hepatectomy for HCC in Eastern Hepatobiliary Surgery Hospital and their clinical and pathological data, death were collected as the follow-up end in September 1, 2008. The survival rate of surgical treatment and the risk factors impacting on prognosis were analyzed. Results The overall survival rate of 1,3,5,10 year of PHT patients were 79.9%, 48.7%, 37.3% and 21.2%, while that of non-PHT group were 82.7%, 54.8%, 42.4% and 29.7% respectively. There were no significant statistical differences between the two groups (P>0.05). Tumor number>1, microvascular invasion, tumor without or with incomplete capsule, tumor size>10 cm and HBsAg-positive were independent risk factors for survival. Conclusion Portal hypertension is not a contraindication of hepatectomy for the patients with hepatocellular carcinoma. As long as the patients have good liver function, they can get a better survival rate after hepatectomy.

Objective To prospectively investigate the relationship between preoperative depression and recurrence in patients with hepatocellular carcinoma(HCC) after hepatectomy.Methods From January 2009 to January,a total of 124 HCC patients who underwent hepatectomy were preoperatively measured depression SDS score for 3~5 days.Using median SDS score as the cutoff value,We divided the patients into high depression score group and low depression score group.Follow-up ended on 31st March 2012.Kaplan-Meier survival analysis was used to assess the relationship between preoperative depression and postoperative recurrence.The Cox proportional hazards model analysis was used to distinguish independent risk factor for HCC recurrence.Results The mean preoperative depression score(SDS score) of patients with HCC was significantly higher than that of the national norm(P= 0.007).The 1,2-year cumulative recurrence rates of high and low depression group were: 9.5%,11.4% vs.19.1%,37.2%,respectively(P=0.036).Further multivariate analysis showed that the independent prognostic factors as follows: SDS score,microvascular invasion,tumor size,and multiple nodules(P0.005).Conclusions The preoperative depression and recurrence of HCC patients are closely related.The prevention and treatment of depression are beneficial to the decrease of recurrence rate in patients with HCC.

<正>1临床资料患者女,45岁。因反复发作右上腹不适1个月,发现右肝占位性病变2周入院。无发热、黄疸、腹痛。查体未见明显阳性体征。B超示:肝右叶可见一个8.5 cm×7.4 cm强回声区,边界不清晰,内部回声分布不均匀,内可见1.61 cm×1.63 cm的无回声区。

Objective To research the expression of Snail protein in Hepatocellular Carcinama(HCC)and its correlation with the clinicopathological characteristics and prognosis after hepatectomy.Methods Immunohistochemical SP method was used to assess the expression of Snail protein in 103 cases of HCC tissues and 25 cases normal liver tissues.The clinicopathological features of HCC were also collected and quantified.The relationship between Snail protein expression and prognosis after surgery was investigated.Results Snail located mainly in plasma of HCC cells.Snail had higher expression in HCC and almost no expression in normal tissue.The positive rate of Snail in HCC was 51.5%,which was significantly higher than that in normal liver tissue(16%,P<0.05).The expression of Snail in HCC was significantly related with pTNM staging,with/without tumor capsule,and with/without microvascular invasion(P<0.05).The 5-year overall survival rate was significant lower in the HCC cases with the positively expression of Snail than in the HCC cases with negatively expression(P<0.05).Conclusion The prognosis and overall survival are correlated with the expression of Snail protein.Snial might be an important biological marker for prognosis of HCC after surgery.