肝细胞癌根治性切除术后复发患者不同局部治疗方法疗效比较

doi:10.3877/cma.j.issn.2095-3232.2018.04.012

目的

探讨肝细胞癌（肝癌）根治性切除术后复发的几种局部治疗方法的疗效。

方法

回顾性分析2012年6月至2013年6月在华中科技大学同济医学院附属同济医院行肝癌根治性切除术后复发的78例患者临床资料。患者均签署知情同意书，符合医学伦理学规定。其中男72例，女6例；年龄25～73岁，中位年龄52岁；共185个复发病灶。根据术后首发病灶的直径（D）将患者分为2组：D<3 cm组（55例）、D≥3 cm组（23例）；同时，D<3 cm的病灶按治疗方法分为3组：微波（MWA）组（97个）、MWA+TACE组（21个）、TACE组（35个）。采用Kaplan-Meier生存曲线和Log-rank检验进行生存分析，率的比较采用χ²检验。

结果

D<3 cm组总体生存明显优于D≥3 cm组（χ²=12.65，P<0.05）；其中D<3 cm组2、3年生存率及显效率分别为98.11%、80.00%、78.18%，D≥3 cm相应为73.91%、47.82%、39.13%，差异有统计学意义（χ²=11.69，8.07，11.13；P<0.05）。MWA组、TACE组1、2、3年疗效维持率分别为63.91%、48.45%、22.68%和17.14%、14.29%、5.71%；有效率及显效率分别为98.97%、93.81%和85.71%、62.86%。MWA组的1、2年疗效维持率明显优于TACE组（χ²=22.53，10.49；P<0.05/3）；MWA组有效率及显效率明显优于TACE组（χ²=10.41，20.00；P<0.05/3）。

结论

肝癌根治性切除术后复发患者的预后与复发病灶的直径密切相关。病灶直径<3 cm患者预后明显好于直径≥3 cm患者。直径<3 cm时，局部治疗可首先考虑MWA治疗。

关键词: 癌，肝细胞, 肝切除术, 导管消融术, 化学栓塞，治疗性

Objective

To compare the efficacy of several local therapies for patients with hepatocellular carcinoma (HCC) recurrence after radical resection.

Methods

Clinical data of 78 patients with HCC recurrence after radical resection in Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology from June 2012 to June 2013 were analyzed retrospectively. The informed consents of all patients were obtained and the local ethical committee approval was received. There were 72 males and 6 females, with an age of 25-73 years, median age of 52 years and 185 recurrent lesions. The patients were divided into 2 groups according to the diameter (D) of focal lesion first relapsed after operation: group D<3 cm (n=55) and group D≥3 cm (n=23). Meanwhile, lesion D<3 cm were divided into 3 subgroups according to different treatments: group microwave (MWA, 97 lesions), group MWA+TACE (21 lesions) and group TACE (35 lesions). Survival analysis was performed using Kaplan-Meier survival curve and Log-rank test, and rates were compared using Chi-square test.

Results

The total survival of group D<3 cm was significantly better than that of group D≥3 cm (χ²=12.65, P<0.05). The 2- and 3-year survival and marked improvement rate of group D<3 cm were 98.11%, 80.00% and 78.18%, respectively, and those of group D≥3 cm were 73.91%, 47.82% and 39.13%, respectively, where significant differences were observed (χ²=11.69, 8.07, 11.13; P<0.05). The 1-, 2- and 3-year efficacy maintenance rate of group MWA was 63.91%, 48.45% and 22.68%, respectively, and those of group TACE was 17.14%, 14.29% and 5.71%, respectively. Their efficacy and marked improvement rate were 98.97%, 93.81% and 85.71% and 62.86%, respectively. The 1- and 2-years efficacy maintenance rate of group MWA were significantly better than those of group TACE (χ²=22.53, 10.49; P<0.05/3). The efficacy and marked improvement rate of group MWA were significantly better than those of group TACE (χ²=10.41, 20.00; P<0.05/3).

Conclusions

The prognosis of patients with HCC recurrence after radical resection is closely related to the diameter of recurrent lesion. The prognosis of patients with a lesion diameter <3 cm is better than that of patients with a lesion diameter≥3 cm. For patients with lesion diameter <3 cm, MWA can be first considered as a local treatment.

Key words: Carcinoma, hepatocellular, Hepatectomy, Catheter ablation, Chemoembolization, therapeutic

图1 肝癌复发局部治疗后影像学检查图

表1 D< 3 cm组与D≥3 cm组肝癌患者一般资料比较（例）

参数		D<3 cm组	D≥3 cm组	统计值	P值
性别		?	?	χ²=0.05	>0.05
?	男	51	21	?	?
?	女	4	2	?	?
年龄（岁）		51±11	50±10	t=0.40	>0.05
乙型病毒性肝炎（例）		53	22	χ²=0.02	>0.05
Child-Pugh分级		?	?	χ²=0.02	>0.05
?	A	53	22	?	?
?	B	2	1	?	?
?	C	0	0	?	?
AFP≥200 μg/L		16	8	χ²=0.25	>0.05
首次复发灶（个）		?	?	χ²=0.98	>0.05
?	单发	46	17	?	?
?	多发	9	6	?	?

表1 D< 3 cm组与D≥3 cm组肝癌患者一般资料比较（例）

参数		D<3 cm组	D≥3 cm组	统计值	P值
性别		?	?	χ²=0.05	>0.05
?	男	51	21	?	?
?	女	4	2	?	?
年龄（岁）		51±11	50±10	t=0.40	>0.05
乙型病毒性肝炎（例）		53	22	χ²=0.02	>0.05
Child-Pugh分级		?	?	χ²=0.02	>0.05
?	A	53	22	?	?
?	B	2	1	?	?
?	C	0	0	?	?
AFP≥200 μg/L		16	8	χ²=0.25	>0.05
首次复发灶（个）		?	?	χ²=0.98	>0.05
?	单发	46	17	?	?
?	多发	9	6	?	?

图2 D<3 cm组与D≥3 cm组肝癌患者Kaplan-Meier生存曲线

表2 MWA组、MWA+TACE组和TACE组肝癌患者疗效及预后比较（%）

组别	病灶数	有效率	显效率	疗效维持率
组别	病灶数	有效率	显效率	1年	2年	3年
MWA组	97	98.97	93.81	63.91	48.25	22.68
MWA+TACE组	21	100.00	95.24	76.19	38.09	19.04
TACE组	35	85.71	62.86	17.14	14.29	5.71
P值^a	?	>0.05/3	>0.05/3	>0.05/3	>0.05/3	>0.05/3
P值^b	?	<0.05/3	<0.05/3	<0.05/3	<0.05/3	>0.05/3
P值^c	?	>0.05/3	<0.05/3	<0.05/3	>0.05/3	>0.05/3

表2 MWA组、MWA+TACE组和TACE组肝癌患者疗效及预后比较（%）

组别	病灶数	有效率	显效率	疗效维持率
组别	病灶数	有效率	显效率	1年	2年	3年
MWA组	97	98.97	93.81	63.91	48.25	22.68
MWA+TACE组	21	100.00	95.24	76.19	38.09	19.04
TACE组	35	85.71	62.86	17.14	14.29	5.71
P值^a	?	>0.05/3	>0.05/3	>0.05/3	>0.05/3	>0.05/3
P值^b	?	<0.05/3	<0.05/3	<0.05/3	<0.05/3	>0.05/3
P值^c	?	>0.05/3	<0.05/3	<0.05/3	>0.05/3	>0.05/3

[1]	Ferlay J, Shin HR, Bray F, et al. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008[J]. Int J Cancer, 2010, 127(12):2893-2917.
[2]	Chen JG, Zhang SW. Liver cancer epidemic in China: past, present and future[J]. Semin Cancer Biol, 2011, 21(1):59-69.
[3]	Torre LA, Bray F, Siegel RL, et al. Global cancer statistics, 2012[J]. CA Cancer J Clin, 2015, 65(2):87-108.
[4]	中华医学会外科学分会肝脏外科学组．肝细胞癌外科治疗方法的选择专家共识（2016年第3次修订）[J]．中华消化外科杂志，2017,16(2):113-115.
[5]	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.
[6]	Yamakado K, Nakatsuka A, Takaki H, et al. Early-stage hepatocellular carcinoma: radiofrequency ablation combined with chemoembolization versus hepatectomy[J]. Radiology, 2008, 247(1):260-266.
[7]	Kirikoshi H, Saito S, Yoneda M, et al. Outcome of transarterial chemoembolization monotherapy, and in combination with percutaneous ethanol injection, or radiofrequency ablation therapy for hepatocellular carcinoma[J]. Hepatol Res, 2009, 39(6):553-562.
[8]	Bruix J, Sherman M, American Association for the Study of Liver Diseases. management of hepatocellular carcinoma: an update[J]. Hepatology, 2011, 53(3):1020-1022.
[9]	Arrieta O, Cacho B, Morales-Espinosa D. The progressive elevation of alpha fetoprotein for the diagnosis of hepatocellular carcinoma in patients with liver cirrhosis[J]. BMC Cancer, 2007(7):28.
[10]	An C, Rakhmonova G, Choi JY, et al. Liver imaging reporting and data system (LI-RADS) version 2014: understanding and application of the diagnostic algorithm[J]. Clin Mol Hepatol, 2016, 22(2):296-307.
[11]	Marrero JA, Hussain HK, Nghiem HV, et al. Improving the prediction of hepatocellular carcinoma in cirrhotic patients with an arterially-enhancing liver mass[J]. Liver Transpl, 2005, 11(3):281-289.
[12]	Song ZZ. Diagnosis of hepatic nodules 20 mm or smaller in cirrhosis: prospective validation of the noninvasive diagnostic criteria for hepatocellular carcinoma[J]. Hepatology, 2008, 47(6):2145-2146.
[13]	Choi JY, Lee JM, Sirlin CB. CT and MR imaging diagnosis and staging of hepatocellular carcinoma: part Ⅱ. extracellular agents, hepatobiliary agents, and ancillary imaging features[J]. Radiology, 2014, 273(1):30-50.
[14]	Sergio A, Cristofori C, Cardin R, et al. Transcatheter arterial chemoembolization (TACE) in hepatocellular carcinoma (HCC): the role of angiogenesis and invasiveness[J]. Am J Gastroenterol, 2008, 103(4):914-921.
[15]	Xiong ZP, Yang SR, Liang ZY, et al. Association between vascular endothelial growth factor and metastasis after transcatheter arterial chemoembolization in patients with hepatocellular carcinoma[J]. Hepatobiliary Pancreat Dis Int, 2004, 3(3):386-390.
[16]	Song BC, Chung YH, Kim JA, et al. Association between insulin-like growth factor-2 and metastases after transcatheter arterial chemoembolization in patients with hepatocellular carcinoma: a prospective study[J]. Cancer, 2001, 91(12):2386-2393.
[17]	Maluccio MA, Covey AM, Porat LB, et al. Transcatheter arterial embolization with only particles for the treatment of unresectable hepatocellular carcinoma[J]. J Vasc Interv Radiol, 2008, 19(6):862-869.
[18]	Llovet JM, Real MI, Montaña X, et al. Arterial embolisation or chemoembolisation versus symptomatic treatment in patients with unresectable hepatocellular carcinoma: a randomised controlled trial[J]. Lancet, 2002, 359(9319):1734-1739.
[19]	Kulik LM, Carr BI, Mulcahy MF, et al. Safety and efficacy of 90Y radiotherapy for hepatocellular carcinoma with and without portal vein thrombosis[J]. Hepatology, 2008, 47(1):71-81.
[20]	Maluccio M, Covey AM, Gandhi R, et al. Comparison of survival rates after bland arterial embolization and ablation versus surgical resection for treating solitary hepatocellular carcinoma up to 7 cm[J]. J Vasc Interv Radiol, 2005, 16(7):955-961.
[21]	Mulier S, Ni Y, Jamart J, et al. Local recurrence after hepatic radiofrequency coagulation: multivariate meta-analysis and review of contributing factor[J]. Ann Surg, 2005, 242(2):158-171.
[22]	Lu XY, Xi T, Lau WY, et al. Pathobiological features of small hepatocellular carcinoma: correlation between tumor size and biological behavior[J]. J Cancer Res Clin Oncol, 2011, 137(4):567-575.
[23]	Guo W, He X, Li Z, et al. Combination of transarterial chemoembolization (TACE) and radiofrequency ablation (RFA) vs. surgical resection (SR) on survival outcome of early hepatocellular carcinoma: a meta-analysis[J]. Hepatogastroenterology, 2015, 62(139):710-714.
[24]	Vivarelli M, Guglielmi A, Ruzzenente A, et al. Surgical resection versus percutaneous radiofrequency ablation in the treatment of hepatocellular carcinoma on cirrhotic liver[J]. Ann Surg, 2004, 240(1):102-107.
[25]	Ruzzenente A, Guglielmi A, Sandri M, et al. Surgical resection versus local ablation for HCC on cirrhosis: results from a propensity case-matched study[J]. J Gastrointest Surg, 2012, 16(2):301-311.

[1]	钟锴, 蒋铁民, 张瑞青, 吐尔干艾力·阿吉, 邵英梅, 郭强. 加速康复外科在肝囊型棘球蚴病肝切除术中的应用分析[J/OL]. 中华普通外科学文献(电子版), 2024, 18(06): 425-429.
[2]	李华志, 曹广, 刘殿刚, 张雅静. 不同入路下行肝切除术治疗原发性肝细胞癌的临床对比[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 52-55.
[3]	常小伟, 蔡瑜, 赵志勇, 张伟. 高强度聚焦超声消融术联合肝动脉化疗栓塞术治疗原发性肝细胞癌的效果及安全性分析[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 56-59.
[4]	冯旺, 马振中, 汤林花. CT扫描三维重建在肝内胆管细胞癌腹腔镜肝切除术中的临床研究[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 104-107.
[5]	赖全友, 高远, 汪建林, 屈士斌, 魏丹, 彭伟. 三维重建技术结合腹腔镜精准肝切除术对肝癌患者术后CD4+、CD8+及免疫球蛋白水平的影响[J/OL]. 中华普外科手术学杂志(电子版), 2024, 18(06): 651-654.
[6]	唐梅, 周丽, 牛岑月, 周小童, 王倩. ICG荧光导航的腹腔镜肝切除术临床意义[J/OL]. 中华普外科手术学杂志(电子版), 2024, 18(06): 655-658.
[7]	屈翔宇, 张懿刚, 李浩令, 邱天, 谈燚. USP24及其共表达肿瘤代谢基因在肝细胞癌中的诊断和预后预测作用[J/OL]. 中华普外科手术学杂志(电子版), 2024, 18(06): 659-662.
[8]	杭轶, 杨小勇, 李文美, 薛磊. 可控性低中心静脉压技术在肝切除术中应用的最适中心静脉压[J/OL]. 中华肝脏外科手术学电子杂志, 2024, 13(06): 813-817.
[9]	公宇, 廖媛, 尚梅. 肝细胞癌TACE术后复发影响因素及预测模型建立[J/OL]. 中华肝脏外科手术学电子杂志, 2024, 13(06): 818-824.
[10]	李一帆, 朱帝文, 任伟新, 鲍应军, 顾俊鹏, 张海潇, 曹耿飞, 阿斯哈尔·哈斯木, 纪卫政. 血GP73水平在原发性肝癌TACE疗效评价中的作用[J/OL]. 中华肝脏外科手术学电子杂志, 2024, 13(06): 825-830.
[11]	刘敏思, 李荣, 李媚. 基于GGT与Plt比值的模型在HBV相关肝细胞癌诊断中的作用[J/OL]. 中华肝脏外科手术学电子杂志, 2024, 13(06): 831-835.
[12]	焦振东, 惠鹏, 金上博. 三维可视化结合ICG显像技术在腹腔镜肝切除术治疗复发性肝癌中的应用[J/OL]. 中华肝脏外科手术学电子杂志, 2024, 13(06): 859-864.
[13]	陈晓鹏, 王佳妮, 练庆海, 杨九妹. 肝细胞癌VOPP1表达及其与预后的关系[J/OL]. 中华肝脏外科手术学电子杂志, 2024, 13(06): 876-882.
[14]	袁雨涵, 杨盛力. 体液和组织蛋白质组学分析在肝癌早期分子诊断中的研究进展[J/OL]. 中华肝脏外科手术学电子杂志, 2024, 13(06): 883-888.
[15]	吴警, 吐尔洪江·吐逊, 温浩. 肝切除术前肝功能评估新进展[J/OL]. 中华肝脏外科手术学电子杂志, 2024, 13(06): 889-893.

阅读次数

全文

摘要

选择文件类型/文献管理软件名称

选择包含的内容

Comparison of efficacy of different local therapies for patients with hepatocellular carcinoma recurrence after radical resection

模态框（Modal）标题

选择文件类型/文献管理软件名称

选择包含的内容

Comparison of efficacy of different local therapies for patients with hepatocellular carcinoma recurrence after radical resection