接受NSS治疗的早期肾细胞癌患者术后MIC综合结局影响因素分析及预测模型构建

doi:10.3760/cma.j.cn371439-20230512-00136

摘要/Abstract

摘要：

目的探讨接受保留肾单位手术（NSS）治疗的T_1b期肾细胞癌患者术后手术切缘、热缺血时间联合术后严重并发症（MIC）综合结局影响因素并构建预测模型。方法选取2017年1月至2022年1月于三二〇一医院接受NSS治疗的T_1b期肾细胞癌患者174例为研究对象，根据术后是否实现MIC综合结局，将患者分为MIC组（n=66）和非MIC组（n=108）。采用单因素和多因素分析患者术后MIC综合结局的独立影响因素，根据影响因素构建列线图预测模型并采用受试者操作特征（ROC）曲线评估该模型的预测价值。结果 MIC组和非MIC组患者体质量指数（t=2.81，P=0.006）、病灶形态学（χ²=41.41，P<0.001）、热缺血时间（t=16.92，P<0.001）、术后24 h内肌酐升高值（t=16.79，P<0.001）、术后24 h内血红蛋白（Hb）下降值（t=9.33，P<0.001）、围手术期并发症（χ²=21.31，P<0.001）、R.E.N.A.L.评分（t=4.74，P<0.001）、PADUA评分（t=3.21，P=0.002）及梅奥肾周粘连指数（t=22.28，P<0.001）比较，差异均有统计学意义。多因素分析显示，体质量指数（OR=0.31，95%CI为0.13~0.74，P=0.007）、病灶形态学（OR=0.36，95%CI为0.22~0.59，P<0.001）、PADUA评分（OR=0.37，95%CI为0.17~0.81，P=0.013）及梅奥肾周粘连指数（OR=0.43，95%CI为0.24~0.70，P=0.004）均是接受NSS治疗的T_1b期肾细胞癌患者术后MIC综合结局的独立影响因素。根据筛选出的变量所构建的列线图模型的C-index为0.89，具有较高的预测准确性；曲线下面积（AUC）为0.84（95%CI为0.77~0.91），具有良好的预测效能。结论体质量指数、病灶形态学、PADUA评分及梅奥肾周粘连指数均为接受NSS治疗的T_1b期肾细胞癌患者术后能否实现MIC综合结局的独立影响因素，以此构建的列线图模型具有较高的预测准确性。

关键词: 癌，肾细胞, 肾切除术, 切缘, 热缺血, 手术后并发症

Abstract:

Objective To investigate the influencing factors of postoperative surgical margin， warm ischemia time and severe postoperative complication （MIC） comprehensive outcome in patients with stage T_1b renal cell carcinoma treated with nephron sparing surgery （NSS） and to establish a predictive model. Methods One hundred and seventy-four patients with stage T_1b renal cell carcinoma treated with NSS were retrospectively chosen in the period from January 2017 to January 2022 in 3201 Hospital. All patients were divided into MIC group （n=66） and non-MIC group （n=108） according to whether MIC was achieved after surgery or not. Univariate and multivariate analysis were used to evaluate the independent influencing factors of postoperative MIC comprehensive outcome， and a nomogram prediction model was constructed according to the influencing factors and its predictive value was evaluated using receiver operating characteristic （ROC） curve. Results There were statistically significant differences in the body mass index （t=2.81， P=0.006）， lesion morphology （χ²=41.41， P<0.001）， hot ischemia time （t=16.92， P<0.001）， creatinine increase within 24 h after surgery （t=16.79， P<0.001）， hemoglobin （Hb） decreased within 24 h after surgery （t=9.33， P<0.001）， perioperative complications （χ²=21.31， P<0.001）， R.E.N.A.L. score （t=4.74， P<0.001）， PADUA score （t=3.21， P=0.002） and Mayo perirenal adhesion index （t=22.28， P<0.001） in MIC group and non-MIC group. Multivariate analysis showed that body mass index （OR=0.31， 95%CI： 0.13-0.74， P=0.007）， lesion morphology （OR=0.36， 95%CI： 0.22-0.59， P<0.001）， PADUA score （OR=0.37， 95%CI： 0.17-0.81， P=0.013） and Mayo perirenal adhesion index （OR=0.43， 95%CI： 0.24-0.70， P=0.004） were all independent factors of postoperative MIC comprehensive outcomes in patients with stage T_1b renal cell carcinoma treated with NSS. The C-index of the nomogram model built according to the selected variables was 0.89 with high prediction accuracy； area under the curve （AUC） was 0.84 （95%CI： 0.77-0.91）， and it had good predictive performance. Conclusion Body mass index， lesion morphology， PADUA score and Mayo perirenal adhesion index are independent influencing factors for the MIC comprehensive outcome of patients with stage T_1b renal cell carcinoma after NSS treatment. The nomogram model based on the above indicators has better predictive performance.

Key words: Carcinoma， renal cell, Nephrectomy, Margins of excision, Warm ischemia, Postoperative complications

李升平, 石永柱, 马锋. 接受NSS治疗的早期肾细胞癌患者术后MIC综合结局影响因素分析及预测模型构建[J]. 国际肿瘤学杂志, 2023, 50(12): 723-728.

Li Shengping, Shi Yongzhu, Ma Feng. Influencing factors analysis and prediction model construction of postoperative MIC comprehensive outcome in patients with early renal cell carcinoma treated with NSS[J]. Journal of International Oncology, 2023, 50(12): 723-728.

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参考文献 24

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影响因素	MIC组（n=66）	非MIC组（n=108）	t/χ²值	P值
性别
男	48	82	0.22	0.638
女	18	26	0.22	0.638
年龄（岁）	59.65±10.61	57.91±10.25	1.06	0.289
体质量指数（kg/m²）	23.98±2.89	25.26±2.96	2.81	0.006
病灶位置
左肾	34	58	0.08	0.779
右肾	32	50	0.08	0.779
肿瘤最大径（cm）	4.76±1.20	4.83±1.29	0.36	0.717
病灶纵向位置
上下极	40	61	0.29	0.593
中间	26	47	0.29	0.593
病灶横向位置
外侧	54	83	0.60	0.437
内侧	12	25	0.60	0.437
病灶是否外凸
是	62	101	0.04	0.833
否	4	7	0.04	0.833
病灶形态学
圆形	64	54
小叶形	2	33	41.41	<0.001
不规则形	0	21
病理组织学类型
肾透明细胞癌	53	87
肾乳头状细胞癌	8	11	0.28	0.871
肾嫌色细胞癌	5	10
术式
开放	1	2	<0.01	>0.999
腹腔镜	65	106	<0.01	>0.999
手术入路
腹腔	35	53	0.26	0.613
后腹腔	31	55	0.26	0.613
切缘状态
阳性	0	1	<0.01	>0.999
阴性	66	107	<0.01	>0.999
手术时间（min）	149.65±23.61	154.91±25.85	1.38	0.171
热缺血时间（min）	16.41±2.85	28.80±5.51	16.92	<0.001
术中出血量（ml）	98.71±18.65	101.35±19.84	0.88	0.378
术后住院时间（d）	7.50±1.29	7.67±1.41	0.81	0.417
术后24 h内肌酐升高值（μmol/L）	12.27±1.57	16.79±1.95	16.79	<0.001
术后24 h内Hb下降值（μmol/L）	11.73±3.40	18.22±5.78	9.33	<0.001
围手术期并发症
无	61	65
Ⅰ~Ⅱ级	5	33	21.31	<0.001
Ⅲ~Ⅳ级	0	10
R.E.N.A.L.评分（分）	7.46±1.60	8.73±1.89	4.74	<0.001
PADUA评分（分）	8.23±2.57	9.58±2.88	3.21	0.002
C-index评分（分）	1.67±0.36	1.73±0.42	1.00	0.318
DAP评分（分）	7.02±1.35	7.17±1.38	0.71	0.482
梅奥肾周粘连指数	0.51±0.12	1.05±0.20	22.28	<0.001

影响因素	b值	SE值	Wald值	OR值	95%CI	P值
体质量指数	-1.17	0.44	7.07	0.31	0.13~0.74	0.007
病灶形态学	-1.02	0.25	16.65	0.36	0.22~0.59	<0.001
热缺血时间	-1.35	1.11	1.48	0.26	0.03~2.28	0.223
术后24 h内肌酐升高值	-1.02	0.84	1.47	0.36	0.07~1.87	0.224
术后24 h内Hb下降值	-1.66	0.92	3.26	0.19	0.03~1.15	0.071
围手术期并发症	1.25	1.02	1.50	3.49	0.47~25.77	0.220
R.E.N.A.L.评分	-1.58	1.14	1.92	0.21	0.02~1.92	0.165
PADUA评分	-0.99	0.40	6.13	0.37	0.17~0.81	0.013
梅奥肾周粘连指数	-0.85	0.30	8.03	0.43	0.24~0.70	0.004