直径≤5 cm单发肝癌合并肝硬化手术方式选择及切缘宽度对预后的影响

Impact of surgical approach and resection margin width on prognosis in patients with solitary hepatocellular carcinoma ≤5 cm complicated by liver cirrhosis

摘要:

背景与目的 直径≤5 cm的单发肝细胞癌（HCC）合并肝硬化患者以手术切除作为首选根治性治疗方式，但在肝功能储备受限的背景下，手术方式选择及切缘宽度的最佳策略仍存在争议。本研究旨在分析不同手术方式及切缘宽度对该类患者术后预后的影响，筛选影响预后的独立危险因素，并构建预后预测模型，为临床手术决策提供依据。方法 回顾性分析2020年1月—2022年6月接受手术治疗的直径≤5 cm单发HCC合并肝硬化患者280例，剔除失访病例后共272例纳入分析。根据术后3年预后结局分为预后良好组和预后不良组。比较两组在临床特征、肿瘤特性及手术相关因素方面的差异，采用多因素Logistic回归分析筛选影响预后的独立危险因素，并据此构建预后预测模型，利用受试者工作特征（ROC）曲线评价模型的预测效能。结果 多因素Logistic回归分析显示，非解剖性肝切除（OR=4.221，95% CI=2.031~8.732）、切缘宽度0.5~<1 cm（OR=2.863，95% CI=1.542~5.318）及切缘宽度<0.5 cm（OR=5.155，95% CI=2.481~10.692）、肝功能Child-Pugh B级（OR=3.127，95% CI=1.451~6.723）和肝功能Child-Pugh C级（OR=6.890，95% CI=2.132~22.351）、肿瘤直径增大（OR=1.891，95% CI=1.211~2.952）及存在大血管侵犯（OR=3.781，95% CI=1.653~8.672）均为术后预后不良的独立危险因素（均P<0.05）。基于上述因素构建的Logistic预测模型ROC曲线下面积为0.935（95% CI=0.892~0.978），敏感度为90.21%，特异度为86.45%，最佳截断值为0.46。结论 对于直径≤5 cm单发HCC合并肝硬化患者，在肝功能储备允许的前提下，优先选择解剖性肝切除并保证切缘宽度≥1 cm，有助于改善术后预后。基于手术因素与临床特征构建的预测模型对患者预后评估具有较高参考价值，可为个体化手术决策提供支持。

Abstract:

Background and Aims Surgical resection remains the preferred curative treatment for patients with solitary hepatocellular carcinoma (≤5 cm) complicated by liver cirrhosis. However, optimal strategies regarding surgical approach and resection margin width remain controversial due to limited hepatic functional reserve in these patients. This study aimed to evaluate the impact of surgical methods and margin width on postoperative prognosis, identify independent prognostic factors, and develop a prognostic prediction model to support clinical decision-making.Methods A retrospective analysis was conducted on 280 patients with solitary hepatocellular carcinoma ≤5 cm in diameter complicated by liver cirrhosis who underwent surgical treatment between January 2020 and June 2022. After excluding patients lost to follow-up, 272 cases were included in the final analysis. Patients were stratified into favorable and poor prognosis groups based on 3-year postoperative outcomes. Differences in clinical characteristics, tumor features, and surgery-related variables between the two groups were compared. Multivariate Logistic regression analysis was performed to identify independent prognostic factors, on the basis of which a prognostic prediction model was established and its predictive performance was evaluated using ROC curve analysis.Results Multivariate Logistic regression analysis demonstrated that non-anatomical hepatectomy (OR=4.221, 95% CI=2.031-8.732), resection margin width of 0.5-1 cm (OR=2.863, 95% CI=1.542-5.318) or <0.5 cm (OR=5.155, 95% CI=2.481-10.692), Child-Pugh grade B (OR=3.127, 95% CI=1.451-6.723) and grade C (OR=6.890, 95% CI=2.132-22.351), increased tumor diameter (OR=1.891, 95% CI=1.211-2.952), and macrovascular invasion (OR=3.781, 95% CI=1.653-8.672) were identified as independent risk factors for poor postoperative prognosis (P<0.05). The Logistic prediction model achieved an area under the ROC curve of 0.935 (95% CI=0.892-0.978), with a sensitivity of 90.21%, a specificity of 86.45%, and an optimal cut-off value of 0.46.Conclusion For patients with solitary hepatocellular carcinoma ≤5 cm accompanied by liver cirrhosis, anatomical hepatectomy with a resection margin of at least 1 cm is associated with improved postoperative outcomes when hepatic functional reserve permits. The proposed prognostic model provides a valuable tool for individualized surgical planning and risk stratification.