Zhao Shoujie, Zhu Yejing, Zhu Jinming, Wang Bo, Wang Enxin, Zhu Jun, Wen Liangzhi, Zhao Yan, Yang Man, Zuo Luo, Fan Jiahao, Jia Jia, Wu Wenbing, Ren Weirong, Chen Xing, Li Jing, Qi Xingshun, Du Xilin, Liu Lei
State Key Laboratory of Holistic Intergrative Management of Gastrointestinal Cancers and Xijng Hospital of Digestive Diseases, Fourth Military Medical University, No. 127 Changlexi Road, Xi'an, 710032, China.
Department of General Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, China.
Surg Endosc. 2025 May 16. doi: 10.1007/s00464-025-11785-3.
BACKGROUND: Hypohepatia limits the feasibility of therapeutic options for hepatocellular carcinoma (HCC), negatively affecting patient prognosis. Established guidelines for the treatment strategies of HCC patients with hypohepatia are lacking. This study was performed to evaluate therapeutic benefits between liver resection (LR) and interventional treatments using ablation or transarterial chemoembolization (TACE) in such population. METHODS: Survival analyses were performed using the Kaplan-Meier method and log-rank test. The Cox proportional hazards regression models were used to analyze potential risk factors associated with prognosis. Multivariate regression and propensity score regression adjustment analyses were applied to adjust for baseline confounding variables. Restricted cubic spline curves were used to assess the association between prognostic index and risk of death or progression on a continuous scale. RESULTS: Of the enrolled 5774 HCC patients with hypohepatia, 506 (8.8%), 2326 (40.3%) and 2942 (51.0%) underwent ablation, LR and TACE, respectively. A tentative analysis of the overall cohort demonstrated that a high degree of heterogeneity existed in this population, while LR rendered a possible tendency to survival benefit over ablation and TACE through adjustment for baseline confounding variables. After categorizing the patients according to the indication of ablation treatment, the indisputable superiority of LR over ablation and TACE in terms of OS and DFS before and after adjustments were evident and the survival advantages of LR were consistent across all pre-specified subgroups. Individualized treatment decision analyses based on restricted cubic spline curves demonstrated that LR group presented the lowest risk of death and disease progression. CONCLUSIONS: HCC patients with hypohepatia could obtain survival benefits through surgical and non-surgical treatment approaches. LR appears to confer a significant survival benefit compared with interventional treatments using ablation or TACE, even for selected intermediate and advanced populations.
背景：肝储备功能减退限制了肝细胞癌（HCC）治疗方案的可行性，对患者预后产生负面影响。目前缺乏针对肝储备功能减退的HCC患者治疗策略的既定指南。本研究旨在评估肝切除术（LR）与使用消融或经动脉化疗栓塞术（TACE）的介入治疗在此类人群中的治疗效果。 方法：采用Kaplan-Meier法和对数秩检验进行生存分析。使用Cox比例风险回归模型分析与预后相关的潜在危险因素。应用多变量回归和倾向评分回归调整分析来调整基线混杂变量。使用限制立方样条曲线以连续尺度评估预后指数与死亡或进展风险之间的关联。 结果：在纳入的5774例肝储备功能减退的HCC患者中，分别有506例（8.8%）、2326例（40.3%）和2942例（51.0%）接受了消融、肝切除术和TACE。对整个队列的初步分析表明，该人群存在高度异质性，而通过调整基线混杂变量，肝切除术相比消融和TACE可能具有生存获益倾向。根据消融治疗适应证对患者进行分类后，肝切除术在调整前后的总生存期（OS）和无病生存期（DFS）方面相对于消融和TACE具有无可争议的优势，且肝切除术的生存优势在所有预先指定的亚组中均一致。基于限制立方样条曲线的个体化治疗决策分析表明，肝切除组的死亡和疾病进展风险最低。 结论：肝储备功能减退的HCC患者可通过手术和非手术治疗方法获得生存获益。与使用消融或TACE的介入治疗相比，肝切除术似乎能带来显著的生存获益，即使对于部分中晚期患者亦是如此。
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