目的:探讨术前ALBI评分预测肝癌患者肝移植术后生存情况的临床价值。方法:回顾性分析青岛大学附属医院自2017年1月至2019年12月的180例肝癌肝移植患者的临床资料。采用受试者工作曲线(ROC)评价ALBI分级、MELD评分、ALBI评分对肝癌患者肝移植生存情况的预测能力,根据最佳界值将患者分为高ALBI组和低ALBI组。Kaplan-Meier法绘制生存曲线。结果:ALBI评分判断肝癌肝移植患者术后生存情况的ROC曲线下面积是0.577,最佳界值是−2.24。根据最佳界值将患者分为ALBI ≤ −2.24组和ALBI > −2.24组,低ALBI组肝癌肝移植患者术后总体生存率较高ALBI组高,两组差异均有统计学意义(P < 0.05)。结论:术前ALBI评分对肝癌肝移植患者术后生存情况有一定的预测价值。 Objective: To investigate the clinical value of preoperative ALBI score in predicting the survival of patients with liver cancer after liver transplantation. Methods: We retrospectively analyzed the clinical data of 180 patients with liver transplantation for hepatocellular carcinoma from January 2017 to December 2019 in the Affiliated Hospital of Qingdao University. The receiver working curve (ROC) was used to evaluate the predictive ability of ALBI grade, MELD score and ALBI score on the survival of liver transplantation in patients with hepatocellular carcinoma, and the patients were divided into high ALBI group and low ALBI group according to the best cut-off value. Kaplan-Meier method is used to draw survival curve. Cox proportional regression model is used to analyze the risk factors of liver transplantation prognosis in patients with hepatocellular carcinoma. Results: The area under the ROC curve of ALBI score for judging the survival of patients with liver cancer af-ter liver transplantation was 0.577, and the optimal cutoff value was −2.24. The patients were di-vided into ALBI ≤ −2.24 group and ALBI > −2.24 group according to the optimal cut-off value. The overall survival rate of patients with hepatocellular carcinoma after liver transplantation in low ALBI group is higher than that in high ALBI group, and the difference between the two groups is statistically significant (P < 0.05). Conclusion: Preoperative ALBI score has a certain predictive val-ue in predicting the survival of patients with hepatocellular carcinoma after liver transplantation.
目的:探讨术前ALBI评分预测肝癌患者肝移植术后生存情况的临床价值。方法:回顾性分析青岛大学附属医院自2017年1月至2019年12月的180例肝癌肝移植患者的临床资料。采用受试者工作曲线(ROC)评价ALBI分级、MELD评分、ALBI评分对肝癌患者肝移植生存情况的预测能力,根据最佳界值将患者分为高ALBI组和低ALBI组。Kaplan-Meier法绘制生存曲线。结果:ALBI评分判断肝癌肝移植患者术后生存情况的ROC曲线下面积是0.577,最佳界值是−2.24。根据最佳界值将患者分为ALBI ≤ −2.24组和ALBI > −2.24组,低ALBI组肝癌肝移植患者术后总体生存率较高ALBI组高,两组差异均有统计学意义(P < 0.05)。结论:术前ALBI评分对肝癌肝移植患者术后生存情况有一定的预测价值。
肝癌,肝移植,生存分析,ALBI评分
Xue Wang, Jianxun Liu, Meijing Zhu, Xin Yang, Cuiping Zhang*
Department of Gastroenterology, The Affiliated Hospital of Qingdao University, Qingdao Shandong
Received: May 8th, 2022; accepted: May 25th, 2022; published: Jun. 9th, 2022
Objective: To investigate the clinical value of preoperative ALBI score in predicting the survival of patients with liver cancer after liver transplantation. Methods: We retrospectively analyzed the clinical data of 180 patients with liver transplantation for hepatocellular carcinoma from January 2017 to December 2019 in the Affiliated Hospital of Qingdao University. The receiver working curve (ROC) was used to evaluate the predictive ability of ALBI grade, MELD score and ALBI score on the survival of liver transplantation in patients with hepatocellular carcinoma, and the patients were divided into high ALBI group and low ALBI group according to the best cut-off value. Kaplan-Meier method is used to draw survival curve. Cox proportional regression model is used to analyze the risk factors of liver transplantation prognosis in patients with hepatocellular carcinoma. Results: The area under the ROC curve of ALBI score for judging the survival of patients with liver cancer after liver transplantation was 0.577, and the optimal cutoff value was −2.24. The patients were divided into ALBI ≤ −2.24 group and ALBI > −2.24 group according to the optimal cut-off value. The overall survival rate of patients with hepatocellular carcinoma after liver transplantation in low ALBI group is higher than that in high ALBI group, and the difference between the two groups is statistically significant (P < 0.05). Conclusion: Preoperative ALBI score has a certain predictive value in predicting the survival of patients with hepatocellular carcinoma after liver transplantation.
Keywords:Hepatocellular Carcinoma, Liver Transplantation, Survival Analysis, ALBI Score
Copyright © 2022 by author(s) and Hans Publishers Inc.
This work is licensed under the Creative Commons Attribution International License (CC BY 4.0).
http://creativecommons.org/licenses/by/4.0/
肝癌是我国最常见的恶性肿瘤之一,根据国家癌症中心发布的数据显示我国肝癌新发病例位居恶性肿瘤第4位,死亡居恶性肿瘤第2位 [
回顾性分析自2017年1月至2019年12月在青岛大学附属医院接受肝移植手术的180例肝癌患者的临床资料。纳入标准:1) 组织病理学诊断为肝癌;2) 年龄 ≥ 18周岁;3) 首次接受肝移植手术。排除标准:1) 其他组织来源的恶性肿瘤;2) 年龄小于18岁;3) 多器官联合移植;4) 劈离式肝移植;5) 临床资料不完整。本研究获得青岛大学附属医院医学伦理委员会批准。
收集患者一般临床资料:性别、年龄、体重指数(Body mass index, BMI)、吸烟史、饮酒史、HBsAg,手术资料:手术方式、无肝期、失血量,术前的实验室资料:甲胎蛋白(Alpha fetoprotein, AFP)、白蛋白(Albumin, ALB)、胆红素(Total bilirubin, TBil)、谷丙转氨酶(Alanine aminotransferase, ALT)、谷草转氨酶(Aspartate aminotransferase, AST)、γ-谷氨酰基转移酶(Gamma-glutamyltransferase, GGT)、碱性磷酸酶(Alkaline phosphatase, ALP)、肌酐(Blood urea nitrogen, Scr)、INR (International normalized ratio)、Child-Pugh分级,术后病理资料:肿瘤数目、肿瘤最大直径、微血管侵犯(Microvascular invasion, MVI)、病理分化类型。总生存时间(overall survival, OS)定义为患者手术时间至死亡的时间,或患者手术时间到随访截止时间2022年1月1日。计算肝癌患者肝移植手术前的MELD评分和ALBI评分,具体计算公式如下:
MELD评分计算公式为 [
ALBI评分计算公式为 [
采用SPSS 24.0统计软件进行统计学分析,计量资料采用t检验或Mann Whitney U检验,计数资料采用χ2检验。ROC曲线评价预测能力,并根据cut-off值进行分组。Kaplan-Meier法绘制生存曲线,采用log-rank χ2检验。P < 0.05表示差异有统计学意义。
绘制术前ALBI分级、MELD评分和ALBI评分判断肝癌患者肝移植术后生存情况的ROC曲线结果显示ALBI分级ROC曲线下面积是0.541,MELD评分ROC曲线下面积是0.570,最佳界值是13,ALBI评分ROC曲线下面积是0.577,最佳界值是−2.24。ALBI分级、MELD评分和ALBI评分对肝癌患者肝移植术后OS具有判断一定的能力,ALBI评分判断肝癌患者肝移植术后OS的能力相对较强(图1)。
本研究共纳入180例肝癌肝移植患者,根据ALBI评分ROC曲线的最佳界值将患者分为低ALBI组(ALBI ≤ −2.24)和ALBI组(ALBI > −2.24)。低ALBI组有78例肝癌肝移植患者,高ALBI组102例肝癌肝移植患者。两组患者在ALB、TBil、AST、ALP、INR、Child-Pugh分级、MVI、病理分化类型、MELD评分的差异有统计学意义(P < 0.05,表1)。
截至随访结束,共有52例患者死亡。生存分析显示低ALBI组肝癌患者肝移植术后总体生存率较高ALBI组肝癌患者肝移植术后总体生存率高,差异有统计学意义(P = 0.007,图2)。而ALBI分级为1、2、3级的肝癌肝移植受者术后的生存率差异无统计学意义(P = 0.261,图3)。低MELD组的肝癌肝移植患者术后总体生存率比高MELD组患者高,但差异无统计学意义(P = 0.066,图4)。
图1. ALBI分级、MELD评分、ALBI评分预测肝癌患者肝移植术后OS的ROC曲线
变量 | ALBI ≤ −2.24 (n = 78) | ALBI > −2.24 (n = 102) | t/X2值 | P值 |
---|---|---|---|---|
性别 | ||||
女 | 11 (14.1) | 13 (12.7) | 0.070 | 0.791 |
男 | 67 (85.9) | 89 (87.3) | ||
年龄(岁) | ||||
≤60 | 63 (80.8) | 72 (70.6) | 2.443 | 0.118 |
>60 | 15 (19.2) | 30 (29.4) | ||
BMI | ||||
<24 | 38 (48.7) | 56 (54.9) | 0.677 | 0.410 |
≥24 | 40 (51.3) | 46 (45.1) | ||
吸烟 | ||||
是 | 39 (50) | 46 (45.1) | 0.426 | 0.514 |
否 | 39 (50) | 56 (54.9) | ||
饮酒 | ||||
是 | 29 (37.2) | 46 (45.1) | 1.140 | 0.286 |
否 | 49 (62.8) | 56 (54.9) | ||
HBsAg | ||||
阳性 | 73 (93.6) | 94 (92.2) | 0.135 | 0.713 |
阴性 | 5 (6.4) | 8 (7.8) | ||
手术方式 | ||||
背驮式 | 3 (3.8) | 8 (7.8) | 0.633 | 0.426 |
经典原位 | 75 (96.2) | 94 (92.2) | ||
无肝期(min) | ||||
≤50 | 48 (61.5) | 50 (49) | 2.793 | 0.095 |
>50 | 30 (38.5) | 52 (51) | ||
失血量 | ||||
≤2000 | 71 (91) | 87 (85.3) | 1.353 | 0.245 |
>2000 | 7 (9) | 15 (14.7) | ||
AFP (ng/ml) | ||||
<400 | 56 (71.8) | 71 (69.6) | 0.102 | 0.750 |
≥400 | 22 (28.2) | 31 (30.4) | ||
ALB (g/l) | 41.01 (39.69~44.20) | 32.67 (28.87~34.77) | −10.358 | 0.000 |
TBil (μmol/L) | 19.93 (13.30~30.04) | 40.81 (24.04~106.68) | −6.511 | 0.000 |
ALT (μmol/L) | 33.50 (24.00~64.25) | 39.00 (24.75~63.75) | −0.491 | 0.624 |
AST (μmol/L) | 33.50 (23.75~56.25) | 52.00 (36.00~103.50) | −4.233 | 0.000 |
GGT (U/L) | 62.00 (30.50~112.00) | 84.00 (45.75~166.75) | −2.087 | 0.037 |
ALP (U/L) | 80.00 (62.00~103.50) | 126.50 (89.50~173.50) | −5.390 | 0.000 |
Scr (μmol/L) | 62.49 (54.00~78.25) | 63.50 (49.00~82.25) | −0.082 | 0.934 |
INR | 1.04 (0.96~1.14) | 1.20 (1.07~1.43) | −5.620 | 0.000 |
Child-Pugh分级 | ||||
A | 69 (88.5) | 19 (18.6) | 87.460 | 0.000 |
B | 9 (11.5) | 60 (58.8) | ||
C | 0 | 23 (22.5) | ||
肿瘤数目(个) | ||||
单个 | 43 (55.1) | 65 (63.7) | 1.361 | 0.243 |
多个 | 35 (44.9) | 37 (36.3) | ||
肿瘤最大直径(cm) | ||||
≤5 | 54 (69.2) | 61 (59.8) | 1.703 | 0.192 |
>5 | 24 (30.8) | 41 (40.2) | ||
MVI | ||||
无 | 45 (57.7) | 35 (34.3) | 9.784 | 0.002 |
有 | 33 (42.3) | 67 (65.7) | ||
病理分化类型 | ||||
I-II级 | 51 (65.4) | 48 (47.1) | 5.998 | 0.014 |
III-IV级 | 27 (34.6) | 54 (52.9) | ||
MELD | ||||
≤13 | 74 (94.9) | 57 (55.9) | 33.915 | 0.000 |
>13 | 4 (5.1) | 45 (44.1) |
表1. 不同ALBI分组患者的临床资料
图2. 低ALBI组和高ALBI组肝癌患者肝移植术后生存曲线
图3. ALBI1级、2级和3级肝癌患者肝移植术后生存曲线
图4. 低MELD组和高MLELD组肝癌患者肝移植术后生存曲线
肝移植是目前治疗肝癌的有效手段之一,不仅可根治肿瘤,同时也治愈了肝炎及肝硬化 [
本研究探讨了术前ALBI评分对肝癌肝移植患者术后OS的预测价值。通过ROC曲线确定ALBI评分判断肝癌患者肝移植术后OS的最佳界值为−2.24,根据这一数值把接受同种异体肝移植的肝癌患者分成两组不同的预后队列,高ALBI组肝癌患者肝移植术后生存率较低ALBI组低,差异有统计学意义(P < 0.05),说明肝脏储备功能可以影响肝癌患者肝移植手术后的生存情况。高ALBI组肝癌肝移植患者术后病理结果显示MVI阳性率和病理分化III~IV级的概率均较低ALBI组患者高,两组患者在肝癌病理学特征之间的差异有统计学意义(P < 0.05)。既往研究表明MVI和肝癌较差的病理分级是影响肝癌患者肝移植术后OS的危险因素 [
目前经典的评估肝脏储备功能的模型是Child-Pugh评分,但腹水、肝性脑病这两项指标具有一定的主观性,使得这一评分系统在临床应用中存在主观影响大、分级不准确、分值有区间限制等缺点 [
本研究结果显示ALBI评分预测肝移植生存情况方面的价值优于MELD评分。Tai [
当然本研究也存在一些局限性。本研究只收集一个医学中心的病例资料,且样本数量较小,随访时间短,可能对会影响研究结果。本研究为回顾性分析,可能存在选择偏倚及混杂因素对结果造成的影响。未来期待在探讨ALBI评分预测肝癌患者肝移植术后OS的作用方面有大样本、多中心的前瞻性研究。
综上,本研究显示术前ALBI评分作为预测模型在预测肝癌患者肝移植术后OS有一定的临床价值,ALBI分级和MELD评分尚不能有效地预测肝癌患者肝移植术后的OS。
王 雪,刘建勋,朱美静,杨 鑫,张翠萍. 术前ALBI评分预测肝癌患者肝移植术后生存情况的价值Prognostic Value of Preoperative ALBI Score in Patients with Liver Transplantation for Hepatocellular Carcinoma[J]. 临床医学进展, 2022, 12(06): 5042-5050. https://doi.org/10.12677/ACM.2022.126731