白蛋白-碱性磷酸酶比值在肝细胞癌患者中的预后价值.pdf

Journalof,Jun.2023肝胆外科杂志2 0 2 3年6 月第31卷第3期196白蛋白碱性磷酸酶比值在肝细胞癌患者中的预后价值仇卫民，张云燕，汤小利【摘要】目的技探讨白蛋白碱性磷酸酶比值（albumin to alkalinephosphatase ratio，A A PR）对肝细胞癌（hepatocellularcarcinoma,HCC）患者远期预后的预测价值。方法本研究共纳人12 4例自2 0 15年0 6 月至2 0 19 年0 2 月间于我院收治并接受根治性手术切除的HCC患者，回顾性收集患者的临床病理资料、术前1周的血生化指标及随访生存数据。以0.4作为AA-PR的临界值,将病人分为AAPR0.4(n=80）和AAPR0.4（n=44)两组,分析AAPR与HCC患者临床病理特征及预后的关系。通过Cox风险比例回归模型(LR向前法）评估AAPR在HCC患者中的独立预后价值。结果果AAPR与肿瘤大小（x=10.390，P=0.0 0 1）、T NM 分期（=16.809，P0.0 0 1）、BCL C临床分期（=25.279，P0.0 0 1）、术前血清AFP水平（=8.033，P=0.0 0 5）、血管侵犯（=16.086，P0.4组患者的3年总体生存率分别为13.3%与64.3%，差异具有统计学意义（x=23.538，P 0.0 0 1），低AAPR提示HCC患者预后不佳。多因素分析的结果表明肿瘤直径5cm（H R：4.12 7,9 5%CI:1.0 8 9 15.6 38，P=0.0 37）T NM 期（风险比HR：5.47 9,9 5%置信区间：1.0 9 9 2 7.32 7，P=0.038）、术前血清AFP400ng/mL（风险比HR：2.132，9 5%置信区间：1.32 7 3.42 3，P=0.002）、NL R 2.2（风险比HR：1.716，9 5%置信区间：1.0 0 7 2.9 2 4，P=0.047）及AAPR0.4（风险比HR：1.9 0 1，9 5%置信区间：1.0 2 8 3.515，P=0.040)是HCC患者预后不佳的独立预测因素。结论仑AAPR是评估HCC患者预后的一项有价值的生物标志物，低AAPR提示患者预后不佳。【关键词】肝细胞癌；白蛋白一碱性磷酸酶比值；预后【中图分类号】R 735.7【文献标识码】A【文章编号】1006-4761(2023)03-0196-06Prognostic value of albumin to alkaline phosphatase ratio for hepatocellular carcinoma patients(QIUWei-min,ZHANGYun-yan,TANG Xiao-li.Department of Laboratory Medicine,Lianyungang First Peoples Hospital,Lianyungang222061,China)【A b s t r a c t Objective To evaluate the predictive value of albumin to alkaline phosphatase ratio(AAPR)for long-term surviv-al of hepatocellular carcinoma(HCC)patients.Methods A total of 124 HCC patients who underwent curative resection in our insti-tution from June 2015 to February 2019 were included in this study.The clinicopathological data,preoperative laboratory test withinone week and follow-up information of all patients were retrospectively collected.124 patients were divided into low AAPR(n=80)and high AAPR group(n=44)based on the threshold value of 0.4 The relationships between AAPR and clinicopathological featuresas well as the prognosis of HCC patients were analyzed.Moreover,the independent prognostic significance of AAPR for HCC patientswas further determined by the multivariate Cox proportional hazards regression model(LR).Results The results showed that low AA-PR was significantly correlated with tumor size(X=10.390,P=0.001),TNM stage(x=16.809,P0.001),BCLC clinicalstage(x=25.279,P0.001),preoperative serum AFP level(x=8.033,P=0.005),vascular invasion(x=16.086,P0.4 was 13.3%and 64.3%,respectively,with a significantly statisti-cal difference(x-23.538,P0.4（n=44）两组。1.2随访情况所有患者于术后每36 个月进行1次定期门诊随访,3年后每6 12 个月随访1次。随访期间，所有患者接受腹部超声及肿瘤标志物检测等检查化验，以监测肿瘤有无复发与转移。如发现可疑病变，则进一步完善胸、腹、盆腔CT扫描或磁共振MRI成像或正电子发射断层扫描PET-CT以明确诊断。对于没有回到我院进行定期随访的患者，则以电话询问方式了解其生存状态。本研究的主要终点事件为总体生存（Overall survival，O S)时间，定义为从手术之日至患者因任何原因死亡或最后一次随访的时间间隔，观察时间以月为单位。本研究的中位随访时间为2 3.8 个月（范围：156 个月），末次随访时间截止至2 0 2 0 年8 月，无失访病例。1.3统计学分析采用SPSS21.0软件对数据进行处理与统计学分析，计数资料以频数或百分比形式表示，采用x检验或Fishers精确检验比较各组间计数资料的分布差异。NLR，PL R 及PNI的最佳临界值采用受试者工作特征（Receiver operationcharacteristics，ROC)曲线确定。采用Kaplan-Meier生存曲线评估高、低AAPR患者的总体生存，组间生存差异的比较采用log-rank检验。随后，通过Cox风险比例回归模型(LR向前法)确定肝细胞癌患者的独立预后因素。所有统计分析的P值均为双尾分布,P0.4（n=44)两组。表1展示了AAPR与HCC临床病理参数的关系,结果表明低AAPR(0.4)与肿瘤大小（x=10.390,P=0.001)、T NM 分期（x=16.809,P0.001）、BCL C临床分期（x=25.279,P 0.001）、术前血清AFP水平（=8.033，P=0.005）、血管侵犯（x=16.086，P0.4组的1年，3年总体0 S分别为7 9.1%与6 4.3%，差异具有统计学意义（=23.538，P0.4070.40+0.40-+0.40-副天0.8累积生存函数0.6-0.4-0.20.0一.010.020.030.040.050.060.0总体生存时间图1比较AAPR0.4与 0.4者的总体生存OS表1白白蛋白-碱性磷酸酶比AAPR与肝细胞癌临床病理特征的关系AAPR临床病理变量X值P值0.4(n=80)0.4(n=44)年龄0.0230.87960岁52(65.0%)28(63.6%)60岁28(35.0%)16(36.4%)性别0.3810.537男57(71.3%)29(65.9%)女23(28.8%)15(34.1%)HBV感染1.8720.169无15(18.8%)13(29.5%)有65(81.3%)31(70.5%）肿瘤大小10.3900.0015cm12(15.0%)18(40.9%)5cm68(85.0%)26(59.1%)肿瘤数目3.6230.057单发47(58.8%)18(40.9%)多发33(41.2%)26(59.1%)TNM分期16.8090.001I期10(12.5%)20(45.5%)期70(87.5%)24(54.5%)BCLC分期25.2790.001A期4(5.0%)13(29.5%)B期36(45.0%)26(59.1%)C期40(50.0%)5(11.4%)术前AFP水平8.0330.005400ng/mL39(48.8%)33(75.0%)400ng/mL41(51.3%)11(25.0%)血管侵犯16.0860.001否40(50.0%)38(84.6%)是40(50.0%)6(13.6%)NLR2.4770.116105.940(50.0%)23(52.3%)PNI5.8800.01548.553(66.3%)38(84.6%)48.527(33.8%)6(13.6%)存分析。单因素分析的结果表明性别（P=0.019）、肿瘤大小（P0.001）、肿瘤个数（P=0.008）、T NM分期（P0.001）、BCL C临床分期（P0.001）、术前血清AFP水平（P0.001）、血管侵犯（P0.001)、NL R(P=0.0 0 5)、PL R(P=0.0 0 4)及AAPR(P0.001)是影响HCC患者远期预后的潜在风险因素。随后,将单因素分析中有统计学意义的变量纳人多因素 Cox回归模型中,结果展示,肿瘤直径5cm（风险比HR：4.12 7，9 5%置信区间：1.0 8 9 15.638，P=0.0 37）、T NM 期（风险比HR:5.479,95%置信区间：1.0 9 9 2 7.32 7，P=0.038）、术前JournalofNo.3,Jun.2023肝胆外科杂志2 0 2 3年6 月第31卷第3期199血清AFP400ng/mL(风险比HR:2.13295%置信区间：1.32 7 3.42 3，P=0.002）、NL R 2.2（风险比HR：1.7 16，9 5%置信区间：1.0 0 7 2.9 2 4，P=0.047)及AAPR0.4（风险比HR:1.901，9 5%置信区间：1.0 2 8 3.515，P=0.040）是HCC患者预后不佳的独立预测因素，见表2。表2单、多因素Cox分析影响肝细胞癌患者预后的独立预测因素单因素分析多因素分析临床病理变量HR及9 5%置信区间P值HR及9 5%置信区间P值年龄60us60岁0.937(0.579 1.514)0.789性别女Us男0.522(0.303 0.899)0.0190.709(0.344 1.458)0.349HBV感染是Us否1.135(0.6422.005)0.663肿瘤大小5us 5 cm13.074(4.104 41.649)0.0014.127(1.089 15.638)0.037肿瘤数目多发Us单发1.911(1.1873.078)0.0081.218(0.667 2.222)0.521TNM分期II vs I II19.844(4.85581.102)0.0015.479(1.099 27.327)0.038BCLC分期C vs A-B2.502(1.5723.983)0.0010.914(0.1107.605)0.934血管侵犯是否2.570(1.614 4.091)0.0011.547(0.18812.717)0.685术前AFP水平400 us 400 ng/mL2.879(1.8004.603)0.0012.132(1.3273.423)0.002NLR2.2Us105.9 us 105.92.004(1.251 3.211)0.0041.171(0.696 1.971)0.551PNI0.43.894(2.160 7.020)0.439组,结果表明低AAPR是这些HCC患者的预后不良的独立因素，而整合AAPR的TNM分期系统对患者总体预后的预测效能显著优于单独TNM分期,强调了AAPR的预后价值 12 。Zhang等分析了445例以射频消融作为初始治疗的早期HCC 患者的生存资料,结果表明以0.4作为AAPR的临界值能够将HCC患者的预后进行准确区分，且与Child-Pugh分级、白蛋白胆红素分级（albumin-bilirubin grade）相比，AAPR在预测患者肿瘤复发与长期预后方面Journal of,Jun.2023肝胆外科杂志2 0 2 3年6 月第31卷第3期200具有更大的优势 1本研究中，我们探讨了AAPR与接受根治性手术切除的HCC 患者临床病理参数的关系及其预后意义。结果表明AAPR0.4与更大的肿瘤直径、TNM II期、BCLC临床C期、血清AFP水平升高（400ng/mL）、血管侵犯及低PNI显著相关。这些数据说明低AAPR一定程度上反映了HCC的高侵袭性及其对机体营养免疫功能的慢性消耗。更为重要的是，我们发现AAPR是HCC的独立预后预测因子,AAPR0.4提示患者预后不佳。因此，对于此类患者而言，术后密切随访与积极的个体化治疗对进一步提升远期预后具有至关重要的临床意义。本研究为回顾性设计，尽管有较为严格的人排标准，但人组病例均来自于单中心且样本量有限，潜在的选择性偏倚仍是不可忽视的。在今后的研究中，我们期待更多诊疗中心的加入，以进一步扩大样本量证实AAPR在HCC患者预后评估中的临床价值。综上所述,白蛋白-碱性磷酸酶比值AAPR可以作为HCC患者预后预测的一项有价值的生化指标，低AAPR提示患者预后不佳。参考文献1Siegel RL,Miller KD,Fuchs HE,et al.Cancer Statistics,2021.CA Cancer J Clin,2021,71(1):7-33.DO0I:10.3322/caac.21654.2Feng RM,Zong YN,Cao SM,et al.Current cancer situation in Chi-na:good or bad news from the 2018 Global Cancer Statistics.CancerCommun(Lond),2019,39(1):22.D0I:10.1186/s40880-019-0368-6.3Poon D,Anderson BO,Chen LT,et al.Management of hepatocellu-lar 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carcinoma in an Asian population.J Gastro-enterol Hepatol,2011,26(2):340-347.D0I:10.1111/j.1440-1746.2010.06329.x.21 Wu SJ,Lin YX,Ye H,et al.Prognostic value of alkaline phospha-tase,gamma-glutamyl transpeptidase and lactate dehydrogenase inhepatocellular carcinoma patients treated with liver resection.Int JSurg,2016,36(Pt A):143-151.D0I:10.1016/j.jsu.2016.10.033.三镜联合分期手术治疗急性重症胆管炎临床分析蔡军,刘学停,盛明辉,郑多安,孙艳军,孙登群【摘要】目的扶探讨腹腔镜、胆道镜、十二指肠镜三镜联合分期治疗急性重症胆管炎的方法及临床意义。方法去选取2019年7 月 2 0 2 2 年12 月期间对7 2 例胆囊结石合并胆总管结石导致急性重症胆管炎患者随机分为观察组和对照组，每组各36 例。观察组实施了内镜下经乳头引流，择期行腹腔镜胆囊切除+胆总管探查术，对照组急诊行腹腔镜胆囊切除、胆总管探查术。比较两组手术时间、术中出血量、术后肠道功能恢复时间、术后住院时间、并发症发生率、结石残石率等。结果果两组患者术后胆漏和结石残留方面比较差异无统计学意义（P0.05）。观察组手术时间、术中出血量、肠道功能恢复和术后住院时间明显低于对照组，差异具有统计学意义（P0.05).The operation time,intraoperativeblood loss,recovery of intestinal function and postoperative hospital stay in the observation group were significantly lower than those inthe control group(P0.05).Conclusion Three endoscopes combined with staging treatment of acute severe cholangitis is safe andeffective,rapid recovery,less trauma to patients,and to the greatest extent in line with the current concept of injury control in modernsurgery.Keywordsduodenoscopy;laparoscopy;choledochoscopy;acute cholangitis of severe type;endoscopic transpapillary drain-age【作者单位】武警安徽省总队医院普外科，合肥230041急性重症胆管炎（acute cholangitis of severetype,ACST)是急性胆管炎的严重阶段,亦称急性梗