摘要： 目的 探讨肝细胞癌自发性破裂的危险因素并建立术前临床预测模型。方法 收集2011年3月至2020年5月中国医科大学附属第一医院132例肝细胞癌自发性破裂患者（破裂组）及性别、年龄、体质量指数相匹配的132例未发生肝细胞癌破裂患者（对照组）的临床资料。单因素分析比较2组各项临床指标的差异。将单因素分析具有统计学差异（P < 0.1）指标纳入多因素回归分析，探讨肝细胞癌自发性破裂的危险因素。基于肝细胞癌自发性破裂相关的独立危险因素构建预测列线图。采用受试者操作特征曲线及校准曲线评估列线图的区分度及校准度，并通过Bootstrap自抽样法对预测模型进行验证。结果 单因素分析结果显示，Child-Pugh分级、国际标准化比值、谷丙转氨酶、最大肿瘤直径、肿瘤是否位于肝左叶、瘤内血管强化（增强CT）、肿瘤突出于肝脏表面、肿瘤累及肝段数2组比较有统计学差异（均P < 0.05）。多因素回归分析结果显示，Child-Pugh分级B或C级、最大肿瘤直径>5 cm、增强CT显示瘤内血管强化、肿瘤突出于肝脏表面、国际标准化比值高是肝细胞癌自发性破裂的独立危险因素（均P < 0.05）。本研究成功构建了术前临床预测列线图。预测模型对肿瘤是否会发生自发性破裂的区分力良好，受试者操作特征曲线下面积为0.868。Bootstrap法内部验证结果说明模型预测结果与实际观察值一致性良好。结论 肝细胞癌患者出现肝功能储备差、最大肿瘤直径>5 cm、增强CT检查可见瘤内血管强化、肿瘤突出于肝脏表面、国际标准化比值高时更容易发生肿瘤自发性破裂。构建的术前临床预测模型可以准确识别肝细胞癌自发性破裂风险的高危人群，因此可以尽早对患者进行危险分层，改善患者预后。

肝细胞癌自发性破裂危险因素分析及术前临床预测模型建立

韩帅^1,2, 李晓航¹, 张城硕¹, 杨召铭¹, 李峰¹, 孙宁¹, 张佳林¹

1. 中国医科大学附属第一医院肝胆外科, 沈阳 110001;
2. 宁波大学附属第一医院肝胆外科, 浙江 宁波 315010

收稿日期:2022-11-23出版日期:2023-11-30发布日期:2023-11-07
通讯作者:张佳林E-mail:jlz2000@yeah.net
作者简介:韩帅(1998-),男,医师,硕士.



关键词: 肝细胞癌, 自发性破裂, 危险因素, 术前临床预测模型
Abstract: Objective To identify risk factors associated with spontaneous rupture of hepatocellular carcinoma and construct a preoperative clinical prediction model. Methods Clinical data of 132 patients with spontaneous rupture of hepatocellular carcinoma (rupture group) and 132 patients with non-ruptured hepatocellular carcinoma (control group), matched by sex, age, and body mass index, were obtained from the First Hospital of China Medical University between March 2011 and May 2020. Statistically significant (P < 0.1) factors identified in a univariable analysis were included in a multivariable regression analysis to determine the risk factors for spontaneous rupture of hepatocellular carcinoma. A predictive nomogram was constructed based on independent risk factors associated with spontaneous tumor rupture. Receiver operating characteristic and calibration curves were used to calculate the discriminative power and accuracy of the nomogram, and bootstrap self-sampling was performed to quantify the preoperative clinical prediction model. Results Eight factors including Child-Pugh status, maximum tumor diameter, left-lobe location of the tumor, blood supply vessels visible on contrast-enhanced computed tomography (CT), tumor protruding from the liver surface, number of involved segments, international normalized ratio (INR), and glutamic pyruvic transaminase level exhibited significant difference between the rupture and control groups (all P < 0.05). Five factors including abnormal liver function, maximum tumor diameter >5 cm, high INR, tumor protruding from the liver surface, and blood supply vessels visible on contrast-enhanced CT were identified as independent risk factors for spontaneous rupture of hepatocellular carcinoma (all P < 0.05). The results of predictive nomogram demonstrated that the predictive model has a good discriminative power to predict spontaneous tumor rupture (area under curve=0.868). Conclusion Patients with hepatocellular carcinoma who exhibited poor liver functional reserve, maximum tumor diameter >5 cm, high INR, tumor protruding from the liver surface, or blood supply vessels visible on contrast-enhanced CT were more likely to experience spontaneous tumor rupture. The proposed nomogram could serve as an accurate tool for predicting spontaneous rupture of hepatocellular carcinoma. Therefore, the preoperative clinical prediction model could aid in the early recognition of patients at risk for spontaneous tumor rupture, thereby improving prognosis.
Key words: hepatocellular carcinoma, spontaneous rupture, risk factor, preoperative clinical prediction model
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