超声引导经皮热消融治疗邻近心脏的肝脏恶性肿瘤疗效分析

doi:10.3877/cma.j.issn.2095-3232.2023.01.010

目的

探讨邻近心脏的肝脏恶性肿瘤患者超声引导经皮热消融治疗的疗效及安全性。

方法

回顾性分析2018年6月至2020年12月在中山大学附属第三医院接受热消融治疗的45例邻近心脏的肝脏恶性肿瘤患者临床资料。患者均签署知情同意书，符合医学伦理学规定。其中男35例，女10例；年龄40~80岁，中位年龄60岁；病灶与心脏距离中位数3（1~5）mm；病灶最大直径20（8~64）mm；肝功能Child-Pugh分级A级43例，B级2例；肝细胞癌39例，转移性肝癌6例。观察技术成功率、技术有效率、局部肿瘤进展率、无进展生存期及并发症发生情况。

结果

45例患者共45个病灶，均顺利完成手术，其中采用射频消融31例，微波消融11例，射频联合微波消融3例；采用人工腹水辅助消融10例，人工胸腹水辅助消融1例。围手术期未见明确活动性出血，无肿瘤腹腔种植。术后主要并发症发生率为9%（4/45），其中胆道感染、肝脓肿、窦性心律失常及心力衰竭各1例，经积极干预治疗后好转。消融技术成功率和技术有效率均为100%（45/45）。局部肿瘤进展率7%（3/45），术后中位无进展生存期为10个月，术后3年总体生存率97.7%。

结论

对于邻近心脏的肝脏恶性肿瘤，在合适的手段辅助下，采用超声引导经皮热消融治疗是安全、有效的。

关键词: 肝肿瘤, 超声检查，介入性, 热消融, 射频消融, 微波消融, 治疗结果

Objective

To evaluate the efficacy and safety of ultrasound-guided percutaneous thermal ablation for patients with malignant liver tumors adjacent to the heart.

Methods

Clinical data of 45 patients with malignant liver tumors adjacent to the heart who received thermal ablation in the Third Affiliated Hospital of Sun Yat-sen University from June 2018 to December 2020 were retrospectively analyzed. The informed consents of all patients were obtained and the local ethical committee approval was received. Among them, 35 patients were male and 10 female, aged from 40 to 80 years, with a median age of 60 years. The median distance of the lesions to the heart was 3(1-5) mm. The maximum diameter of lesions was 20(8-64) mm. 43 cases were classified as Child-Pugh grade A and 2 cases of Child-Pugh grade B. 39 patients were diagnosed with hepatocellular carcinoma and 6 cases of metastatic liver cancer. The success rate and effective rate of the ablation, local progression rate, progression-free survival and incidence of complications were observed.

Results

45 lesions were detected in 45 patients and the surgeries of all patients were completed successfully. Among them, 31 cases received radiofrequency ablation, 11 cases of microwave ablation and 3 casesof radiofrequency combined with microwave ablation. 10 cases underwent ablation assisted by artificial ascites and 1 case by artificial hydrothorax and ascites. No active bleeding or abdominal tumor implantation was found during the perioperative period. The incidence of major postoperative complications was 9%(4/45), including 1 case of biliary infection, 1 case of liver abscess, 1 case of sinus arrhythmia and 1 case of heart failure, which were mitigated after active interventions. The success rate and effective rate of thermal ablation were both 100%(45/45). The local progression rate was 7%(3/45), the median progression-free survival was 10 months, and the overall 3-year survival rate was 97.7%.

Conclusions

Assisted by appropriate approaches, ultrasound-guided percutaneous thermal ablation is safe and effective for treating malignant liver tumors adjacent to the heart.

Key words: Liver neoplasms, Ultrasonography, interventional, Thermal ablation, Radiofrequency ablation, Microwave ablation, Treatment outcome

图1 一例邻近心脏的肝脏恶性肿瘤患者超声引导经皮热消融治疗注：a、b为术前增强CT示S2段被膜下病灶原发性肝癌病灶，动脉期呈高增强（a图白色箭头），门静脉期强化减退（b图白色箭头），邻近心脏（b图红色箭头），a为横断面，b为冠状面；c为术中穿刺消融超声造影图像，消融针（红色箭头）首先穿刺消融肿瘤基底部（白色箭头），其后向包膜逐层消融；d为消融术后即时超声造影图像，提示消融灶范围（黄色箭头）覆盖原病灶范围；e、f为消融术后1个月增强CT图像，提示近心脏（红色箭头）病灶热消融范围（黄色箭头）覆盖原病灶（白色箭头）

图2 邻近心脏的肝脏恶性肿瘤热消融术后患者Kaplan-Meier生存曲线注：a为无进展生存曲线；b为总体生存曲线

表1 射频组和微波组肝癌患者疗效与安全性比较

组别	例数^a	年龄[岁，M（Min~Max）]	性别（例，男/女）	病灶直径[mm，M（Min~Max）]	胸腹水辅助（例）	手术时间[min，M（Min~Max）]	术后并发症（例）	技术成功（例）	完全消融（例）	LTP（例）
射频组	31	60（40~80）	25/6	20（11~63）	8	70（33~175）	2	31	31	2
微波组	11	52（42~72）	7/4	25（10~64）	2	40（20~97）	2	11	11	1
统计值		Z=0.857	χ²=0.527	Z=-1.217	χ²=0.010	Z=2.988	χ²=0.293	-	-	χ²=0.000
P值		0.397	0.468	0.231	0.922	0.005	0.589	-	-	1.000

表1 射频组和微波组肝癌患者疗效与安全性比较

组别	例数^a	年龄[岁，M（Min~Max）]	性别（例，男/女）	病灶直径[mm，M（Min~Max）]	胸腹水辅助（例）	手术时间[min，M（Min~Max）]	术后并发症（例）	技术成功（例）	完全消融（例）	LTP（例）
射频组	31	60（40~80）	25/6	20（11~63）	8	70（33~175）	2	31	31	2
微波组	11	52（42~72）	7/4	25（10~64）	2	40（20~97）	2	11	11	1
统计值		Z=0.857	χ²=0.527	Z=-1.217	χ²=0.010	Z=2.988	χ²=0.293	-	-	χ²=0.000
P值		0.397	0.468	0.231	0.922	0.005	0.589	-	-	1.000

表2 胸腹水辅助组与非辅助组肝癌患者疗效与安全性比较

组别	例数	年龄[岁，M（Min~Max）]	性别（例，男/女）	病灶直径[mm，M（Min~Max）]	手术时间[min，M（Min~Max）]	术后并发症（例）	技术成功（例）	完全消融（例）	LTP（例）
辅助组	11	71（51~80）	7/4	23（11~63）	95（54~175）	1	11	11	2
非辅助组	34	56（40~74）	28/6	20（8~64）	64（20~160）	3	34	34	4
统计值		Z=3.326	χ²=0.776	Z=1.530	Z=3.150	χ²=0.000	-	-	χ²=0.001
P值		0.002	0.378	0.133	0.003	1.000	-	-	0.973

表2 胸腹水辅助组与非辅助组肝癌患者疗效与安全性比较

组别	例数	年龄[岁，M（Min~Max）]	性别（例，男/女）	病灶直径[mm，M（Min~Max）]	手术时间[min，M（Min~Max）]	术后并发症（例）	技术成功（例）	完全消融（例）	LTP（例）
辅助组	11	71（51~80）	7/4	23（11~63）	95（54~175）	1	11	11	2
非辅助组	34	56（40~74）	28/6	20（8~64）	64（20~160）	3	34	34	4
统计值		Z=3.326	χ²=0.776	Z=1.530	Z=3.150	χ²=0.000	-	-	χ²=0.001
P值		0.002	0.378	0.133	0.003	1.000	-	-	0.973

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Clinical efficacy of ultrasound-guided percutaneous thermal ablation for malignant liver tumors adjacent to the heart

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Clinical efficacy of ultrasound-guided percutaneous thermal ablation for malignant liver tumors adjacent to the heart