基于术前CT征象构建肾透明细胞癌患者总生存期的列线图

摘要/Abstract

摘要：

目的探讨肾透明细胞癌(ccRCC)患者术前CT征象影响总生存期的独立危险因素并绘制列线图。方法回顾性分析空军军医大学第一附属医院2011年10月至2015年12月术前行CT扫描并最终经病理学证实的ccRCC患者238例。由两名影像科医生对每例患者的CT征象进行评价,并收集患者的一般资料、肾功能检查以及世界卫生组织/国际泌尿病理协会(WHO/ISUP)分级。绘制Kaplan-Meier生存曲线,采用log-rank检验比较生存率。采用Cox比例风险回归进行单变量和多变量分析,并根据多变量分析结果绘制列线图,采用Bootstrap 1000法内部验证后计算C-指数。结果238例患者经3~74个月随访后,死亡组32例,截尾组206例。死亡组患者的肿瘤直径为(65.70±27.29)mm,大于截尾组的(46.25±26.16)mm,差异有统计学意义(t=-3.889,P<0.001)。死亡组患者肿瘤坏死(χ²=45.716,P<0.001)、区域淋巴结肿大(χ²=43.342,P<0.001)、肾周脂肪侵犯(χ²=19.324,P<0.001)的发生率均高于截尾组患者。不同肿瘤直径的ccRCC患者其生存率差异有统计学意义(χ²=17.108,P<0.001)。肿瘤组织出现坏死患者的生存率较无坏死患者低(χ²=48.195,P<0.001);区域淋巴结肿大患者的生存率低于无区域淋巴结肿大的患者(χ²=47.232,P<0.001);出现肾周脂肪侵犯患者的生存率低于未侵犯的患者(χ²=19.964,P<0.001)。不同WHO/ISUP分级ccRCC患者的生存率差异有统计学意义(χ²=27.765,P<0.001)。多变量Cox比例风险回归分析结果显示,CT征象中的肿瘤直径(HR=2.90,95%CI为1.37~6.14,P=0.006)、坏死(HR=8.88,95%CI为3.33~23.69,P<0.001)及区域淋巴结肿大(HR=4.48,95%CI为2.04~9.86,P<0.001)是ccRCC患者死亡的独立危险因素。列线图的C-指数为0.870。结论术前CT征象与ccRCC患者的生存率存在相关性,其中肿瘤直径、肿瘤出现坏死以及区域淋巴结肿大是其死亡的独立危险因素,其列线图具有较高的准确性。

关键词:肾肿瘤,腺癌,透明细胞,体层摄影术,螺旋计算机,列线图表

Abstract:

ObjectiveTo explore the independent risk factors of preoperative CT findings affecting the overall survival of patients with clear cell renal cell carcinoma (ccRCC) and to draw a nomogram.MethodsThe retrospective study was performed on 238 patients with ccRCC who underwent preoperative CT scan and were pathologically confirmed in First Affiliated Hospital of Air Force Medical University from October 2011 to December 2015. CT findings of each patient were evaluated by two radiologists, and general information, renal function examination, and World Health Organization/International Society for Urology and Pathology (WHO/ISUP) grading were collected. The Kaplan-Meier survival curve was plotted, and survival rates were compared using log-rank test. Cox proportional hazard regression was used for univariate and multivariate analysis, and the nomogram was drawn according to the results of multivariate analysis, and the C-index was calculated after internal validation by Bootstrap 1000.ResultsAfter 3-74 months of follow-up for 238 patients, 32 cases were in the death group and 206 cases were in the censored group. The tumor diameter of the death group [(65.70±27.29) mm] was larger than that of the censored group [(46.25±26.16) mm], with a statistically significant difference (t=-3.889,P<0.001). The incidence rate of tumor necrosis (χ²=45.716,P<0.001), regional lymph node enlargement (χ²=43.342,P<0.001) and perirenal fat invasion (χ²=19.324,P<0.001) in the death group were higher than those in the censored group. Survival rates were different in patients with different tumor diameter of ccRCC, with a statistically significant difference (χ²=17.108,P<0.001). The survival rate of patients with tumor necrosis was lower than those without necrosis (χ²=48.195,P<0.001). The survival rate of patients with regional lymph node enlargement was lower than those without regional lymph node enlargement (χ²=47.232,P<0.001). The survival rate of patients with perirenal fat invasion was lower than those without perirenal fat invasion (χ²=19.964,P<0.001). Survival rates were also different in ccRCC patients with different WHO/ISUP grades, with a statistically significant difference (χ²=27.765,P<0.001). In Cox multivariate analysis, tumor diameter (HR=2.90, 95%CI: 1.37-6.14,P=0.006), necrosis (HR=8.88, 95%CI: 3.33-23.69,P<0.001) and regional lymph node enlargement (HR=4.48, 95%CI: 2.04-9.86,P<0.001) in CT findings were independent risk factors for death in patients with ccRCC. The C-index of nomogram was 0.870.ConclusionPreoperative CT findings are correlated with survival rate of patients with ccRCC, in which tumor diameter, tumor necrosis and regional lymph node enlargement are independent risk factors for death, and the nomograms has high accuracy.

Key words:Kidney neoplasms,Adenocarcinoma,clear cell,Tomography,spiral computed,Nomogram

王佳丽, 韩冬, 陈英, 张亚敏, 艾美梅. 基于术前CT征象构建肾透明细胞癌患者总生存期的列线图[J]. 国际肿瘤学杂志, 2020, 47(8): 480-486.

Wang Jiali, Han Dong, Chen Ying, Zhang Yamin, Ai Meimei. Construction of a nomogram of overall survival of patients with clear cell renal cell carcinoma based on preoperative CT findings[J]. Journal of International Oncology, 2020, 47(8): 480-486.

图/表12

图1

表1

两组ccRCC患者的一般资料和实验室检查结果比较($\bar{x}±s$/例)"

参数	截尾组 (n=206)	死亡组 (n=32)	t/χ²值	P值
年龄(岁)	52.08±12.49	54.50±14.17	-1.000	0.318
性别
女	61	9	0.029	0.864
男	145	23
肉眼血尿
无	178	27	0.001	0.972
有	28	5
胁腹部疼痛
无	153	23	0.083	0.774
有	53	9
腹部肿块
无	180	30	0.556	0.456
有	26	2
实验室检查
胱抑素C(mg/L)	1.03±0.28	1.20±0.28	-3.269	0.001
血肌酐(μmol/L)	77.32±21.45	77.41±24.86	-0.020	0.984
尿酸(μmol/L)	364.31±93.93	339.84±116.75	1.324	0.187
WHO/ISUP分级
Ⅰ级	47	2
Ⅱ级	130	15	24.806	<0.001
Ⅲ级	26	11
Ⅳ级	3	4

表1

表2

两组ccRCC患者的影像学征象比较($\bar{x}±s$/例)"

影像学征象	截尾组 (n=206)	死亡组 (n=32)	t/χ²值	P值
肿瘤直径(mm)	46.25±26.16	65.70±27.29	-3.889	<0.001
位置
左侧	100	13	0.696	0.404
右侧	106	19
相对密度
低密度	66	8
等密度	107	16	1.758	0.415
高密度	33	8
坏死
无	156	5	45.716	<0.001
有	50	27
钙化
无	175	25	0.962	0.327
有	31	7
区域淋巴结肿大
无	173	10	43.342	<0.001
有	33	22
肾周脂肪侵犯
无	141	9	19.324	<0.001
有	65	23

表2

图2

图3

图4

图5

图6

图7

表3

238例ccRCC患者预后影响因素的单变量Cox比例风险回归分析结果"

参数	HR值	95%CI	P值
年龄	1.02	0.99~1.05	0.270
性别	1.09	0.50~2.35	0.833
肉眼血尿	1.25	0.48~3.26	0.642
胁腹部疼痛	1.14	0.52~2.45	0.749
腹部肿块	0.49	0.12~2.04	0.324
胱抑素C	3.62	1.64~7.96	0.001
血肌酐	1.00	0.98~1.02	0.936
尿酸	1.00	0.99~1.00	0.211
WHO/ISUP分级
Ⅰ级	参考		<0.001
Ⅱ级	2.70	0.62~11.81	0.188
Ⅲ级	9.06	2.00~41.00	0.004
Ⅳ级	17.81	3.26~97.44	0.001
肿瘤直径(≥57.9 mm)	4.13	1.99~8.57	<0.001
位置	1.34	0.66~2.71	0.422
相对密度
低密度	参考		0.402
等密度	1.19	0.51~2.78	0.692
高密度	1.90	0.71~5.06	0.200
坏死	12.39	5.15~34.79	<0.001
钙化	1.50	0.65~3.47	0.344
区域淋巴结肿大	8.79	4.16~18.57	<0.001
肾周脂肪侵犯	4.89	2.26~10.58	<0.001

表3

参数	HR值	95%CI	P值
肿瘤直径(≥57.9 mm)	2.90	1.37~6.14	0.006
坏死	8.88	3.33~23.69	<0.001
区域淋巴结肿大	4.48	2.04~9.86	<0.001

表4

图8

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