经肝动脉化疗栓塞术联合局部热消融治疗大肝癌的效果及影响因素
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摘要
目的探讨经肝动脉化疗栓塞术(TACE)联合局部热消融治疗大肝癌的临床效果。方法回顾性分析2010年1月-2016年9月在首都医科大学附属北京佑安医院肿瘤微创介入中心接受TACE联合局部热消融治疗的大肝癌患者的临床资料,134例患者中行TACE联合微波消融治疗75例,行TACE联合射频消融治疗共59例。评价患者的消融效果(分为完全消融和部分消融),随访获得完全消融的患者肝内肿瘤复发状况。采用χ2检验和logistic回归分析消融效果的影响因素;采用Kaplan-Meier生存分析和Cox比例风险模型统计其中位无复发生存期并分析影响因素。结果在全部患者中,有88例获得完全消融,46例为部分消融,完全消融率为65. 7%,logistic回归分析分析显示,合并门静脉癌栓[比值比(OR)=5. 051,P=0. 017],肿瘤包膜不完整(OR=4.199,P=0. 007)及肿瘤位于危险部位(OR=4. 967,P=0. 001)是影响消融效果的独立危险因素。获得完全消融的患者其中位无复发生存期是(17. 41±2. 73)个月,1、3、5年的无复发生存率分别为61. 4%、23. 3%和17. 7%,多因素分析显示,肿瘤多发(OR=1. 708,P=0. 041)是其独立危险因素。TACE联合微波消融和TACE联合射频消融2种治疗方式对消融效果(χ2=2. 431,P=0. 119)和肿瘤复发(χ2=3. 292,P=0. 070)的影响差异均无统计学意义。结论合并门静脉癌栓、肿瘤包膜的完整性和肿瘤部位是大肝癌患者消融效果的影响因素,对于获得完全消融的患者,肿瘤数目可用于评估肿瘤复发的危险性。
Objective To investigate the clinical effect of transcatheter arterial chemoembolization( TACE) combined with local thermal ablation in the treatment of large hepatocellular carcinoma( HCC). Methods A retrospective analysis was performed for the clinical data of134 patients with large HCC who underwent TACE combined with local thermal ablation in our center from January 2010 to September 2016.In all patients,75 underwent TACE combined with microwave ablation and 59 underwent TACE combined with radiofrequency ablation. The effect of ablation( complete ablation and partial ablation) was evaluated,and follow-up was performed to observe the recurrence of intrahepatic tumor in patients with complete ablation. The chi-square test and logistic regression analysis were used to evaluate the influencing factors for the effect of ablation,and the Kaplan-Meier survival analysis and the Cox proportional hazards model were used to analyze recurrence-free survival and related influencing factors. Results Of all patients,88 achieved complete ablation and 46 patients achieved partial ablation,resulting in a complete ablation rate of 65. 7%. The logistic regression analysis showed that presence of portal vein tumor thrombus( odds ratio [OR]= 5. 051,P = 0. 017),incomplete tumor capsule( OR = 4. 199,P = 0. 007),and dangerous location of tumor( OR =4. 967,P = 0. 001) were independent risk factors for the effect of ablation. The patients with complete ablation had a median recurrence-free survival of 17. 41 ± 2. 73 months and the 1-,3-,and 5-year recurrence-free survival rates were 61. 4%,23. 3%,and 17. 7%,respectively; the multivariate analysis showed that multiple tumors( OR = 1. 708,P = 0. 041) was an independent risk factor. There were no significant differences between TACE combined with microwave ablation and TACE combined with radiofrequency ablation in the effect of ablation( χ2= 2. 431,P = 0. 119) and tumor recurrence( χ2= 3. 292,P = 0. 070). Conclusion Presence of portal vein tumor thrombus,tumor capsule integrity,and tumor location are important influencing factors for the effect of ablation in patients with large HCC. For patients with complete ablation,the number of tumors can be used to assess the risk of intrahepatic tumor recurrence.
Objective To investigate the clinical effect of transcatheter arterial chemoembolization( TACE) combined with local thermal ablation in the treatment of large hepatocellular carcinoma( HCC). Methods A retrospective analysis was performed for the clinical data of134 patients with large HCC who underwent TACE combined with local thermal ablation in our center from January 2010 to September 2016.In all patients,75 underwent TACE combined with microwave ablation and 59 underwent TACE combined with radiofrequency ablation. The effect of ablation( complete ablation and partial ablation) was evaluated,and follow-up was performed to observe the recurrence of intrahepatic tumor in patients with complete ablation. The chi-square test and logistic regression analysis were used to evaluate the influencing factors for the effect of ablation,and the Kaplan-Meier survival analysis and the Cox proportional hazards model were used to analyze recurrence-free survival and related influencing factors. Results Of all patients,88 achieved complete ablation and 46 patients achieved partial ablation,resulting in a complete ablation rate of 65. 7%. The logistic regression analysis showed that presence of portal vein tumor thrombus( odds ratio [OR]= 5. 051,P = 0. 017),incomplete tumor capsule( OR = 4. 199,P = 0. 007),and dangerous location of tumor( OR =4. 967,P = 0. 001) were independent risk factors for the effect of ablation. The patients with complete ablation had a median recurrence-free survival of 17. 41 ± 2. 73 months and the 1-,3-,and 5-year recurrence-free survival rates were 61. 4%,23. 3%,and 17. 7%,respectively; the multivariate analysis showed that multiple tumors( OR = 1. 708,P = 0. 041) was an independent risk factor. There were no significant differences between TACE combined with microwave ablation and TACE combined with radiofrequency ablation in the effect of ablation( χ2= 2. 431,P = 0. 119) and tumor recurrence( χ2= 3. 292,P = 0. 070). Conclusion Presence of portal vein tumor thrombus,tumor capsule integrity,and tumor location are important influencing factors for the effect of ablation in patients with large HCC. For patients with complete ablation,the number of tumors can be used to assess the risk of intrahepatic tumor recurrence.
引文
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[11]CHEN WY,REN N.Advances in molecular targeted therapy for hepatocellular carcinoma[J].J Clin Hepatol,2018,34(7):1387-1394.(in Chinese)陈万勇,任宁.肝细胞癌分子靶向治疗进展[J].临床肝胆病杂志,2018,34(7):1387-1394.
[12]TAKAKI H,YAMAKADO K,URAKI J,et al.Radiofrequency ablation combined with chemoembolization for the treatment of hepatocellular carcinomas larger than 5 cm[J].J Vasc Interv Radiol,2009,20(2):217-224.
[13]LIM C,MISE Y,SAKAMOTO Y,et al.Above 5 cm,size does not matter anymore in patients with hepatocellular carcinoma[J].World J Surg,2014,38(11):2910-2918.
[14]DELIS SG,BAKOYIANNIS A,TASSOPOULOS N,et al.Hepatic resection for hepatocellular carcinoma exceeding Milan criteria[J].Surg Oncol,2010,19(4):200-207.
[15]CHANG YJ,CHUNG KP,CHANG YJ,et al.Long-term survival of patients undergoing liver resection for very large hepatocellular carcinomas[J].Br J Surg,2016,103(11):1513-1520.
[16]ZHANG W,TAN Y,JIANG L,et al.Liver resection associated with better outcomes for single large hepatocellular carcinoma located in the same section[J].Medicine(Baltimore),2017,96(10):e6246.
[17]SONG SH,GUO J,ZOU C.Factors influencing postoperative recurrence in patients with primary liver cancer after hepatectomy[J].J Pract Hepatol,2017,20(2):203-206.(in Chinese)宋书红,郭俊,邹灿.肝癌手术切除术后复发相关因素分析[J].实用肝脏病杂志,2017,20(2):203-206.
[18]IEZZI R,POMPILI M,LA TORRE MF,et al.Radiofrequency ablation plus drug-eluting beads transcatheter arterial chemoembolization for the treatment of single large hepatocellular carcinoma[J].Dig Liver Dis,2015,47(3):242-248.
[19]SHI M,ZHANG CQ,ZHANG YQ,et al.Micrometastases of solitary hepatocellular carcinoma and appropriate resection margin[J].World J Surg,2004,28(4):376-381.
[20]REN ZG.Immunotherapy for hepatocellular carcinoma[J].JClin Hepatol,2018,34(7):1371-1373.(in Chinese)任正刚.肝细胞癌的免疫治疗[J].临床肝胆病杂志,2018,34(7):1371-1373.
[21]XU LF,SUN HL,CHEN YT,et al.Large primary hepatocellular carcinoma:Transarterial chemoembolization monotherapy versus combined transarterial chemoembolization-percutaneous microwave coagulation therapy[J].J Gastroenterol Hepatol,2013,28(3):456-463.
[22]BIOLATO M,MARRONE G,RACCO S,et al.Transarterial chemoembolization(TACE)for unresectable HCC:A new life begins?[J].Eur Rev Med Pharmacol Sci,2010,14(4):356-362.
[23]TANG C,SHEN J,FENG W,et al.Combination therapy of radiofrequency ablation and transarterial chemoembolization for unresectable hepatocellular carcinoma:A retrospective study[J].Medicine(Baltimore),2016,95(20):e3754.
[24]CHANG P,ZHANG HY,XIAO M.Efficacy of transcatheter arterial chemoembolization alone or combined with microwave ablation in treatment of primary large liver cancer:A comparetive analysis[J].J Clin Hepatol,2015,31(6):880-885.(in Chinese)常鹏,张洪义,肖梅.单纯经肝动脉化疗栓塞术及其联合微波消融治疗原发性大肝癌的疗效对比分析[J].临床肝胆病杂志,2015,31(6):880-885.
[2]BALOGH J,VICTOR DR,ASHAM EH,et al.Hepatocellular carcinoma:A review[J].J Hepatocell Carcinoma,2016,3:41-53.
[3]GUIMARAES M,UFLACKER R.Locoregional therapy for hepatocellular carcinoma[J].Clin Liver Dis,2011,15(2):395-421.
[4]SHI J,SUN Q,WANG Y,et al.Comparison of microwave ablation and surgical resection for treatment of hepatocellular carcinomas conforming to Milan criteria[J].J Gastroenterol Hepatol,2014,29(7):1500-1507.
[5]HOCQUELET A,BALAGEAS P,LAURENT C,et al.Radiofrequency ablation versus surgical resection for hepatocellular carcinoma within the Milan criteria:A study of 281 Western patients[J].Int J Hyperthermia,2015,31(7):749-757.
[6]LEE DH,LEE JM,LEE JY,et al.Radiofrequency ablation of hepatocellular carcinoma as first-line treatment:Long-term results and prognostic factors in 162 patients with cirrhosis[J].Radiology,2014,270(3):900-909.
[7]GUO XD,SUN SS,LI WD,et al.Effects of transcatheter arterial chemoembolization combined with percutaneous radiofrequency ablation on patients with intermediate stage primary liver cancer[J/CD].Chin J Liver Dis:Electronic Edition,2018,10(2):30-36.(in Chinese)郭晓笛,孙莎莎,李文东,等.肝动脉化疗栓塞术联合射频消融术治疗中期原发性肝癌患者的疗效[J/CD].中国肝脏病杂志:电子版,2018,10(2):30-36.
[8]XU Y,SHEN Q,WANG N,et al.Percutaneous microwave ablation of 5-6 cm unresectable hepatocellular carcinoma:Local efficacy and long-term outcomes[J].Int J Hyperthermia,2016.[Epub ahead of print]
[9]YIN XY,XIE XY,LU MD,et al.Percutaneous thermal ablation of medium and large hepatocellular carcinoma:Long-term outcome and prognostic factors[J].Cancer,2009,115(9):1914-1923.
[10]ZHAI B.Strategy and prospect of thermal ablation for treatment of large hepatocellular carcinoma[J/CD].Eletronic JLiver Tumor,2017,4(4):13-16.(in Chinese)翟博.大肝癌热消融治疗策略及展望[J/CD].肝癌电子杂志,2017,4(4):13-16.
[11]CHEN WY,REN N.Advances in molecular targeted therapy for hepatocellular carcinoma[J].J Clin Hepatol,2018,34(7):1387-1394.(in Chinese)陈万勇,任宁.肝细胞癌分子靶向治疗进展[J].临床肝胆病杂志,2018,34(7):1387-1394.
[12]TAKAKI H,YAMAKADO K,URAKI J,et al.Radiofrequency ablation combined with chemoembolization for the treatment of hepatocellular carcinomas larger than 5 cm[J].J Vasc Interv Radiol,2009,20(2):217-224.
[13]LIM C,MISE Y,SAKAMOTO Y,et al.Above 5 cm,size does not matter anymore in patients with hepatocellular carcinoma[J].World J Surg,2014,38(11):2910-2918.
[14]DELIS SG,BAKOYIANNIS A,TASSOPOULOS N,et al.Hepatic resection for hepatocellular carcinoma exceeding Milan criteria[J].Surg Oncol,2010,19(4):200-207.
[15]CHANG YJ,CHUNG KP,CHANG YJ,et al.Long-term survival of patients undergoing liver resection for very large hepatocellular carcinomas[J].Br J Surg,2016,103(11):1513-1520.
[16]ZHANG W,TAN Y,JIANG L,et al.Liver resection associated with better outcomes for single large hepatocellular carcinoma located in the same section[J].Medicine(Baltimore),2017,96(10):e6246.
[17]SONG SH,GUO J,ZOU C.Factors influencing postoperative recurrence in patients with primary liver cancer after hepatectomy[J].J Pract Hepatol,2017,20(2):203-206.(in Chinese)宋书红,郭俊,邹灿.肝癌手术切除术后复发相关因素分析[J].实用肝脏病杂志,2017,20(2):203-206.
[18]IEZZI R,POMPILI M,LA TORRE MF,et al.Radiofrequency ablation plus drug-eluting beads transcatheter arterial chemoembolization for the treatment of single large hepatocellular carcinoma[J].Dig Liver Dis,2015,47(3):242-248.
[19]SHI M,ZHANG CQ,ZHANG YQ,et al.Micrometastases of solitary hepatocellular carcinoma and appropriate resection margin[J].World J Surg,2004,28(4):376-381.
[20]REN ZG.Immunotherapy for hepatocellular carcinoma[J].JClin Hepatol,2018,34(7):1371-1373.(in Chinese)任正刚.肝细胞癌的免疫治疗[J].临床肝胆病杂志,2018,34(7):1371-1373.
[21]XU LF,SUN HL,CHEN YT,et al.Large primary hepatocellular carcinoma:Transarterial chemoembolization monotherapy versus combined transarterial chemoembolization-percutaneous microwave coagulation therapy[J].J Gastroenterol Hepatol,2013,28(3):456-463.
[22]BIOLATO M,MARRONE G,RACCO S,et al.Transarterial chemoembolization(TACE)for unresectable HCC:A new life begins?[J].Eur Rev Med Pharmacol Sci,2010,14(4):356-362.
[23]TANG C,SHEN J,FENG W,et al.Combination therapy of radiofrequency ablation and transarterial chemoembolization for unresectable hepatocellular carcinoma:A retrospective study[J].Medicine(Baltimore),2016,95(20):e3754.
[24]CHANG P,ZHANG HY,XIAO M.Efficacy of transcatheter arterial chemoembolization alone or combined with microwave ablation in treatment of primary large liver cancer:A comparetive analysis[J].J Clin Hepatol,2015,31(6):880-885.(in Chinese)常鹏,张洪义,肖梅.单纯经肝动脉化疗栓塞术及其联合微波消融治疗原发性大肝癌的疗效对比分析[J].临床肝胆病杂志,2015,31(6):880-885.