Department of Hepatobiliary Surgery, Guangxi Medical University Cancer Hospital, Nanning, 530021, China.
Department of Hepatic Suegery VI, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, 225 Changhai Road, Shanghai, 200438, China.
BMC Cancer. 2024 Jun 25;24(1):764. doi: 10.1186/s12885-024-12535-9.
Clinically significant portal hypertension (CSPH) seriously affects the feasibility and safety of surgical treatment for hepatocellular carcinoma (HCC) patients. The aim of this study was to establish a new surgical scheme defining risk classification of post-hepatectomy liver failure (PHLF) to facilitate the surgical decision-making and identify suitable candidates for individual hepatectomy among HCC patients with CSPH.
Hepatectomy is the preferred treatment for HCC. Surgeons must maintain a balance between the expected oncological outcomes of HCC removal and short-term risks of severe PHLF and morbidity. CSPH aggravates liver decompensation and increases the risk of severe PHLF thus complicating hepatectomy for HCC.
Multivariate logistic regression and stochastic forest algorithm were performed, then the independent risk factors of severe PHLF were included in a nomogram to determine the risk of severe PHLF. Further, a conditional inference tree (CTREE) through recursive partitioning analysis validated supplement the misdiagnostic threshold of the nomogram.
This study included 924 patients, of whom 137 patients (14.8%) suffered from mild-CSPH and 66 patients suffered from (7.1%) with severe-CSPH confirmed preoperatively. Our data showed that preoperative prolonged prothrombin time, total bilirubin, indocyanine green retention rate at 15 min, CSPH grade, and standard future liver remnant volume were independent predictors of severe PHLF. By incorporating these factors, the nomogram achieved good prediction performance in assessing severe PHLF risk, and its concordance statistic was 0.891, 0.850 and 0.872 in the training cohort, internal validation cohort and external validation cohort, respectively, and good calibration curves were obtained. Moreover, the calculations of total points of diagnostic errors with 95% CI were concentrated in 110.5 (range 76.9-178.5). It showed a low risk of severe PHLF (2.3%), indicating hepatectomy is feasible when the points fall below 76.9, while the risk of severe PHLF is extremely high (93.8%) and hepatectomy should be rigorously restricted at scores over 178.5. Patients with points within the misdiagnosis threshold were further examined using CTREE according to a hierarchic order of factors represented by the presence of CSPH grade, ICG-R15, and sFLR.
This new surgical scheme established in our study is practical to stratify risk classification in assessing severe PHLF, thereby facilitating surgical decision-making and identifying suitable candidates for individual hepatectomy.
临床显著门静脉高压症（CSPH）严重影响肝癌（HCC）患者手术治疗的可行性和安全性。本研究旨在建立一种新的手术方案，定义肝切除术后肝衰竭（PHLF）的风险分类，以利于手术决策，并确定 CSPH 肝癌患者个体肝切除的合适人选。
肝切除术是 HCC 的首选治疗方法。外科医生必须在 HCC 切除的预期肿瘤学结果与严重 PHLF 和发病率的短期风险之间保持平衡。CSPH 加重肝功能失代偿，增加严重 PHLF 的风险，从而使 HCC 的肝切除术复杂化。
采用多变量逻辑回归和随机森林算法，将严重 PHLF 的独立危险因素纳入列线图，以确定严重 PHLF 的风险。此外，通过递归分区分析的条件推理树（CTREE）验证补充了列线图的误诊阈值。
本研究共纳入 924 例患者，其中 137 例（14.8%）为轻度 CSPH，66 例（7.1%）为重度 CSPH 术前确诊。我们的数据显示，术前延长的凝血酶原时间、总胆红素、15 分钟吲哚氰绿潴留率、CSPH 分级和标准剩余肝体积是严重 PHLF 的独立预测因素。通过纳入这些因素，列线图在评估严重 PHLF 风险方面具有良好的预测性能，其一致性统计在训练队列、内部验证队列和外部验证队列中分别为 0.891、0.850 和 0.872，且获得了良好的校准曲线。此外，95%CI 内总诊断错误点的计算集中在 110.5（范围 76.9-178.5）。当分数低于 76.9 时，提示低风险严重 PHLF（2.3%），可行肝切除术，而分数超过 178.5 时，严重 PHLF 的风险极高（93.8%），肝切除术应严格限制。位于误诊阈值内的患者根据 CSPH 分级、ICG-R15 和 sFLR 等因素的存在，按照层次顺序使用 CTREE 进一步检查。
本研究建立的新手术方案在评估严重 PHLF 时，可实用地对风险分类进行分层，从而有利于手术决策，并确定 CSPH 肝癌患者个体肝切除的合适人选。
