【摘要】 目的探究肝癌患者白蛋白-胆红素(ALBI)评分、中性粒细胞/淋巴细胞比值(NLR)等临床特征与原发性肝癌中医证型的相关性,建立原发性肝癌中医辨证分型的临床判断模型。方法选取2016年11月1日-2018年10月31日在广西医科大学附属肿瘤医院收治的经病理或临床诊断为原发性肝癌的初治患者289例,并对患者进行中医辨证分型。符合正态分布的计量资料采用单因素方差分析;不符合正态分布的计量资料采用Kruskal-Wallis H检验;计数资料组间比较采用χ~2检验。将单因素分析显示存在显著差异的资料进行logistic回归分析,采用ROC曲线评价这些临床特征对肝癌中医辨证分型的判断效能。结果 ALBI(F=5. 487,P <0. 001)、NLR(χ~2=30. 146,P <0. 001)、BCLC分期(χ~2=71. 973,P <0. 001)、Alb (χ~2=18. 887,P <0. 001)、TBil (χ~2=12. 138,P=0. 007)、ALT(χ~2=18. 001,P <0. 001)、AST(χ~2=12. 067,P=0. 007)、中性粒细胞绝对值(F=6. 262,P <0. 001)、淋巴细胞绝对值(F=2. 934,P=0. 034)、肝内原发肿瘤直径(F=4. 905,P=0. 002)、腹水(χ~2=9. 034,P=0. 021)、门静脉癌栓(χ~2=13. 434,P=0. 004)、肝外转移灶(χ~2=2. 529,P=0. 002)在肝癌各中医证型间比较差异均有统计学意义。Logistic回归分析提示:ALT和BCLC分期是湿热蕴结型的独立判断因素[比值比(OR)=1. 002、0. 591,95%可信区间(95%CI):1. 003～1. 021、0. 413～0. 845,P值均<0. 05]; ALT和BCLC分期也是肝郁脾虚型的独立判断因素(OR=0. 985、3. 191,95%CI:0. 974～0. 997、2. 042～4. 986,P值均<0. 05); TBil、Alb、ALBI是气滞血瘀型的独立判断因素(OR=0. 966、1. 259、0. 088,95%CI:0. 937～0. 995、1. 064～1. 490、0. 013～0. 607,P值均<0. 05)。ROC曲线分析结果:ALT和BCLC分期判断湿热蕴结型的ROC曲线下面积为0. 662(95%CI:0. 605～0. 717,敏感度69. 4%,特异度58%),ALT截断值为36 U/L,BCLC分期截断值为C期; ALT和BCLC分期判断肝郁脾虚型的ROC曲线下面积为0. 753(95%CI:0. 699～0. 801,敏感度72. 7%,特异度68. 2%),ALT截断值为64 U/L,BCLC分期截断值为B期; TBil、Alb和ALBI判断气滞血瘀型的ROC曲线下面积为0. 634(95%CI:0. 576～0. 690,敏感度56. 7%,特异度65. 3%),TBil截断值为28. 4μmol/L,Alb截断值为37. 8 g/L,ALBI截断值为1. 95。结论基于ALT、BCLC分期、TBil、Alb和ALBI构建的临床判断模型可区分肝癌中医证型的湿热蕴结型、肝郁脾虚型和气滞血瘀型,该判断模型简便、客观,值得临床关注。更多还原

【Abstract】 Objective To investigate the association of the clinical features of liver cancer patients,including albumin-bilirubin( ALBI)and neutrophil-lymphocyte ratio( NLR),with the traditional Chinese medicine( TCM) syndrome types of primary liver cancer,and to establish a clinical judgment model for TCM syndrome differentiation of primary liver cancer. Methods A total of 289 previously untreated patients who were admitted to The Affiliated Tumor Hospital of Guangxi Medical University from November 1,2016 to October 31,2018 and were diagnosed with primary liver cancer based on pathology or clinical examination were enrolled,and TCM syndrome differentiation was performed for all patients. A one-way analysis of variance was used for comparison of normally distributed continuous data between groups,and the Kruskal-Wallis H test was used for comparison of non-normally distributed continuous data between groups; the chi-square test was used for comparison of categorical data between groups. The data with significant difference in the univariate analysis were included in the logistic regression analysis,and the receiver operating characteristic( ROC) curve was used to evaluate the efficiency of these clinical features in the TCM syndrome differentiation of liver cancer. Results There were significant differences between the patients with different TCM syndrome types of liver cancer in ALBI( F = 5. 487,P < 0. 001),NLR( χ~2= 30. 146,P < 0. 001),BCLC stage( χ~2= 71. 973,P <0. 001),albumin( Alb)( χ~2= 18. 887,P < 0. 001),total bilirubin( TBil)( χ~2= 12. 138,P = 0. 007),alanine aminotransferase( ALT)( χ~2= 18. 001,P < 0. 001),aspartate aminotransferase( χ~2= 12. 067,P = 0. 007),absolute neutrophil count( F = 6. 262,P < 0. 001),absolute lymphocyte count( F = 2. 934,P = 0. 034),diameter of intrahepatic primary tumor( F = 4. 905,P = 0. 002),ascites( χ~2=9. 034,P = 0. 021),portal vein tumor thrombus( χ~2= 13. 434,P = 0. 004),and number of extrahepatic metastatic lesions( χ~2= 2. 529,P= 0. 002). The logistic regression analysis showed that ALT( odds ratio [OR]= 1. 002,95% confidence interval [CI]: 1. 003-1. 021,P< 0. 05) and BCLC stage( OR = 0. 591,95% CI: 0. 413-0. 845,P < 0. 05) were independent factors for judging damp-heat accumulation; ALT( OR = 0. 985,95% CI: 0. 974-0. 997,P < 0. 05) and BCLC stage( OR = 3. 191,95% CI: 2. 042-4. 986,P < 0. 05) were also independent factors for judging liver depression and spleen deficiency; TBil( OR = 0. 966,95% CI: 0. 937-0. 995,P < 0. 05),Alb( OR = 1. 259,95% CI: 1. 064-1. 490,P < 0. 05),and ALBI( OR = 0. 088,95% CI: 0. 013-0. 607,P < 0. 05) were independent factors for judging Qi stagnation and blood stasis. The ROC curve analysis showed that ALT and BCLC stage had an area under the ROC curve( AUC) of 0. 662( 95% CI: 0. 605-0. 717),a sensitivity of 69. 4%,and a specificity of 58% in judging damp-heat accumulation,at the cut-off values of 36 U/L for ALT and stage C for BCLC stage; ALT and BCLC stage had an AUC of 0. 753( 95% CI: 0. 699-0. 801),a sensitivity of 72. 7%,and a specificity of 68. 2% in judging liver depression and spleen deficiency,at the cut-off values of 64 U/L for ALT and stage B for BCLC stage; TBil,Alb,and ALBI had an AUC of 0. 634( 95% CI: 0. 576-0. 690),a sensitivity of 56. 7%,and a specificity of 65. 3% in judging Qi stagnation and blood stasis,at the cut-off values of 28. 4 μmol/L for TBil,37. 8 g/L for Alb,and 1. 95 for ALBI. Conclusion The clinical judgment model based on ALT,BCLC stage,TBil,Alb,and ALBI can differentiate between the TCM syndrome types of damp-heat accumulation,liver depression and spleen deficiency,and Qi stagnation and blood stasis for liver cancer,and this model is simple,convenient,and objective and thus holds promise for clinical application.更多还原