摘要
目的构建术前预测肝内胆管癌(ICC)淋巴结转移的列线图模型,并探讨模型的应用效果。方法回顾性收集2003年1月至2014年1月于海军军医大学东方肝胆外科医院、东部战区总医院或东南大学附属中大医院接受肝部分切除的1031例ICC患者的临床和病理学资料。男性682例,女性349例;平均年龄54.7岁(范围:18~82岁)。行淋巴结清扫(清扫组)562例,未清扫(未清扫组)469例。在清扫组的患者中,采用Lasso回归的方法筛选与淋巴结转移相关的术前变量并建立列线图模型,使用Bootstrap法内部验证模型的区分度及拟合度。根据模型预测概率将纳入的患者分为低中风险组和高风险组,采用倾向性评分匹配(PSM)分析两组中行淋巴结清扫与未清扫患者的总体生存及无复发生存。结果通过Lasso回归方法筛选出与ICC淋巴结转移有关的6个因素,包括乙肝表面抗原、CA19-9、年龄、淋巴结肿大、癌胚抗原和肿瘤最大径,据此建立预测ICC淋巴结转移的列线图模型,曲线下面积为0.764,一致性指数为0.754,一致性曲线的预测概率与实际观测淋巴结转移率一致性良好。分层分析结果显示,淋巴结转移高风险组总体生存及无复发生存差于低中风险组(中位总体生存时间:14.6个月比27.0个月,P<0.01;中位无复发生存时间:9.1个月比15.5个月,P<0.01);在高风险组的患者中,PSM后淋巴结清扫组和未清扫组中位总体生存时间分别为16.7个月和6.3个月(Log-rank检验:P=0.187;Wilcoxon检验:P=0.046),中位无复发生存时间分别为11.0个月和4.8个月(P=0.403);低中风险组中,PSM后清扫组和未清扫组中位总体生存时间分别为22.7个月和26.7个月(P=0.288),中位无复发生存时间分别为13.0个月和14.5个月(P=0.306)。结论该模型可用于ICC淋巴结转移的术前预测及预后分层。对于模型预测为淋巴结转移高风险的患者,应积极清扫;对于预测为低中风险的患者,经权衡利弊后可有选择性地不清扫淋巴结。
Objective Constructing and validating a nomogram model for preoperative prediction of intrahepatic cholangiocarcinoma(ICC)lymph node metastasis to assist decision making during surgery.Methods Retrospectively collecting the clinical and pathological data of 1031 ICC patients who underwent partial hepatectomy at Eastern Hepatobiliary Surgery Hospital of Naval Military Medical University,General Hospital of Eastern Theater Command,or Zhongda Hospital Southeast University from January 2003 to January 2014.There were 682 males and 349 females;mean age was 54.7 years(range:18 to 82 years).There were 562 patients who underwent lymph node dissection and 469 patients who did not.Among the patients in the dissection group,Lasso regression method was used to filtrate preoperative variables related to lymph node metastasis and establish a nomogram.Bootstrap method was used to internally validate the discrimination of the nomogram,and the accuracy of the nomogram was assessed by using calibration curves.Patients were divided into low-moderate and high-risk groups based on model prediction probability.Propensity score matching(PSM)was used to analyze the overall survival(OS)and recurrence-free survival(RFS)of patients with and without lymph node dissection in the two groups,and to judge the importance of lymph node dissection in the two groups.Results Six factors related to ICC lymph node metastasis were determined by Lasso regression,including hepatitis B surface antigen,CA19-9,age,lymphadenopathy,carcinoembryo antigen and maximum tumor diameter.These factors were integrated into a nomogram to predict ICC lymph node metastasis.The aera under curve value was 0.764,and the C-index was 0.754.Stratified analysis showed that OS and RFS in the high-risk group of lymph node metastasis were significantly lower than those in the low-medium risk group(median OS:14.6 months vs.27.0 months,P<0.01;median RFS:9.1 months vs.15.5 months,P<0.01).In the high-risk group,the median OS was 16.7 months and 6.3 months(Log-rank test:P=0.187;Wilcoxon test:P=0.046),and the median RFS was 11.0 months and 4.8 months(P=0.403),respectively in the lymph node dissection group and undissected group after PSM.In the low-medium-risk group,the median OS was 22.7 months and 26.7 months(P=0.288),and the median RFS was 13.0 months and 14.5 months(P=0.306),respectively in the lymph node dissection group and undissected group after PSM.Conclusions The nomogram could be used for preoperative prediction of lymph node metastasis and prognostic stratification in patients with ICC.For patients with high risk of lymph node metastasis predicted by the model,active dissection should be performed.For patients predicted to be at low-moderate risk,lymph node dissection might be optional in some specific cases.
作者
马伟虎
雷正清
余秋石
肖茜茹
汤浩澜
司安锋
杨平华
程张军
Ma Weihu;Lei Zhengqing;Yu Qiushi;Xiao Qianru;Tang Haolan;Si Anfeng;Yang Pinghua;Cheng Zhangjun(Hepato-pancreato-biliary Center,Zhongda Hospital Southeast University,Nanjing 210009,China;Department of Surgical Oncology,General Hospital of Eastern Theater Command,Nanjing 210001,China;Department of Biliary Tract SurgeryⅣ,Eastern Hepatobiliary Surgery Hospital,Naval Military Medical University,Shanghai 200438,China)
出处
《中华外科杂志》
CAS
CSCD
北大核心
2022年第4期363-371,共9页
Chinese Journal of Surgery
基金
国家自然科学基金(81871988)
江苏省重点研发计划(BE2019747)。
关键词
胆管肿瘤
肿瘤转移
肝内胆管细胞癌
淋巴结清扫
列线图
预测
生存分析
Bile duct neoplasms
Neoplasm metastasis
Intrahepatic cholangiocarcinoma
Lymph node dissection
Nomogram
Prediction
Survival analysis
