肝硬化食管胃静脉曲张内镜下序贯治疗患者肝癌病例的回顾性分析

摘要

目的 研究肝硬化食管胃静脉曲张(EGV)患者行内镜下序贯治疗过程发生的肝细胞癌(HCC)病例的危险因素,评估血清甲胎蛋白在随访中监测HCC的价值.方法 以首次食管胃静脉曲张破裂出血(EGVB)并行胃镜下序贯根除治疗的95例肝硬化EGV患者为研究对象,记录临床、实验室检查及影像学资料,随访期间诊断的HCC病例增加记录诊断时甲胎蛋白、肿瘤长径.运用Logstic回归分析寻找HCC发生的危险因素,比较甲胎蛋白阈值分别设为200 ng/ml和20 ng/ml时的诊断效能.结果 在95例肝硬化患者中,随访期间诊断18例HCC,占总病例的20.39％,中位随访时间15个月.1、3、5年HCC累积发病率分别为7.37％、14.74％和17.90％.18例HCC中肿瘤长径≤3 cm的小HCC患者7例,占HCC病例的38.89％.Logistic回归分析表明HCC的危险因素为首次出血时的年龄(OR=1.092,P＜0.05)和较低的血小板计数(OR=0.974,P＜0.05).HCC患者中11例的甲胎蛋白值处于正常参考值范围内,而小HCC中仅有3例患者的甲胎蛋白值高于正常参考值.当甲胎蛋白阈值设为200 ng/ml可发现3例HCC.甲胎蛋白阈值设为20 ng/ml时,可以增加4例HCC诊断,但总体诊断率仅为38.89％,其它均为增强CT、MRI或超声检查发现.结论 肝硬化合并EVB的患者具有较高的肝癌发生率,需重视这部分患者的HCC监测.HCC的危险因素为首次出血时的较大年龄和较低血小板计数.超声联合甲胎蛋白阈值设为20 ng/ml可提高小HCC的发现能力,但仍不够满意,需行更为敏感和客观的增强CT或MRI检查.%Objective To analyze the risk factors of hepatocellular carcinoma (HCC) cases in liver cirrhosis patients who underwent endoscopic sequential therapy for eradication of easophagogastric varices (EGV) and evaluate the value of serum alpha-fetoprotein (AFP) in monitoring HCC during follow-up.Methods A total of 95 liver cirrhosis patients who underwent sequential therapy for eradication of EGV after first onset of easophagogastric variceal bleeding (EGVB) were recruited in this investigation.Clinical,laboratory examination and imaging data were recorded.The AFP level upon diagnosis and long diameter of tumors were also recorded for HCC cases during follow-up.Logistic regression analysis was performed to identify the risk factors of HCC.The diagnostic efficiency of AFP was statistically compared when 200 ng/ml and 20 ng/ml were set as the cut-off points.Results During follow-up of 95 patients with liver cirrhosis,18 patients (20.39％) were diagnosed with HCC.The median follow-up duration was 15 months.The 1-,3-and 5-year cumulative incidence rate of HCC was calculated as 7.37％,14.74％ and 17.90％,respectively.Among 18 HCC cases,the long diameter of tumors was ≤3 cm in 7 cases (38.89％).Logistic regression analysis demonstrated that the age at the first onset of EGVB(OR =1.092,P ＜ 0.05) and low platelet count (OR =0.974,P ＜ 0.05).The AFP level was within the normal range in 11 HCC patients,and the AFP level was higher than normal range in 3 patients with small HCC.Three patients were diagnosed with HCC when the cut-off value of AFP was set at 200 ng/ml.Four patients were newly diagnosed with HCC when the cut-off value of AFP was set at 20 ng/ml.However,the overall diagnostic rate was only 38.89％.The other HHC cases were diagnosed by contrast-enhanced CT,MRI or ultrasound examination.Conclusions Liver cirrhosis patients complicated with EGVB have a high risk of HCC.Widespread attention should be paid to these patients.The risk factors of HCC include old age at the first onset of EGVB and low platelet count.The diagnostic rate of HCC can be enhanced to certain extent when the cut-off value of AFP is set at 20 ng/ml,whereas more sensitive and objective contrast-enhanced CT or MRI should be performed to obtain satisfied diagnostic rate.