血流灌注和肝组织硬度对肝细胞癌射频消融疗效影响的研究

发布时间：2018-05-20 00:18

本文选题：肝细胞癌 + 射频消融　；参考：《中国人民解放军医学院》2016年博士论文

【摘要】：目的：(1)探讨原发性肝细胞癌(Hepatocellular carcinoma, HCC)血流灌注程度对射频消融(Radiofrequency ablation, RFA)台疗参数、温度热场及消融范围的影响,并探讨其影响机制。(2)研究患者肝组织硬度测值(LSM)对HCC射频消融近期疗效的影响。(3)分析HCC射频消融后局部肿瘤进展的危险因素,为进一步优化治疗策略提供相关依据。材料与方法：第一部分：2013年9月-2015年12月在302医院行超声引导RFA治的62例HCC患者共66个病灶,所有病灶均经超声引导组织穿刺活检病理学或两种以上增强影像学明确诊断。入组标准为：(1)肿瘤≤5cm或数目3≤个,最大直径≤3cm;(2)无血管、胆管栓塞及肝外转移;(3)肝功能Child-Pugh A或B级;(4)患者拒绝手术治疗或无手术切除适应证;(5)血浆凝血酶原时间≤25秒,凝血酶原活动度≥40%,血小板计数≥50×109/L;(6)患者自愿受试,签署知情同意书。对HCC病灶行超声造影(CEUS)并进行定量分析,根据曲线下面积(AUC)值,将病灶分为低血流灌注组和高血流灌注组。行RFA时,相关治疗参数包括输出功率、组织阻抗和治疗时间进行记录,治疗同时在消融电极针旁开0.5cm(T1)及1.0cm(T2)处行实时温度监测,所有病灶完成射频消融能量25KJ后,即刻行超声造影CEUS检查,测量消融区长轴径(LAD)、短轴径(SAD)及消融区体积(Volume)。研究HCC血流灌注程度与RFA治疗参数和消融范围之间的关系;研究HCC血流灌注程度对RFA温度热场的影响。第二部分：2013年9月-2015年10月行超声引导RFA治疗的106例患者共114病灶,所有病灶均经超声引导组织穿刺活检病理学或两种以上增强影像学明确诊断。采用FibroScan检测仪对患者行肝组织硬度测量(LSM),以17.5kPa作为临界值,将患者分为高LSM组和低LSM组,研究分析两组病灶在技术有效率(TER)、局部肿瘤进展(LTP)率等方面的差异。第三部分：2012年9月～2015年10月在302行超声引导RFA治疗的99例HCC患者107个病灶,所有病灶均经超声引导组织穿刺活检病理学或两种以上增强影像学明确诊断。所有患者均有完整的CEUS血流灌注参数、肝组织硬度测值LSM等检查,平均随访时间10.6个月。采用单因素分析和Cox比例风险多因素分析方法,研究HCC患者RFA治疗后局部肿瘤进展的危险因素,绘制生存曲线。结果：1、(1)HCC血流灌注程度与RFA平均输出功率、作用时间呈线性正相关,与组织阻抗呈线性负相关;(2)低血流灌注组HCC内部测温点T1、T2均高于高血流灌注组,两组差异有统计意义;(3)HCC血流灌注程度与RFA治疗能量为25KJ的消融区长轴径LAD、短轴径SAD和消融体积Volume均呈线性负相关,关系分别为y=-0.18×10-3x+3.2711(r=-0.662,p=0.00)、y=-0.21×10-3x+2.9988(r=-0.765, p=0.00)和y=-0.0031x+15.892(r=-0.761,p=0.00)、2、高LSM组与低LSM组HCC技术有效率分别为94.4%和95.3%,两组间无统计学差异：高LSM组和低LSM组HCC局部肿瘤进展率分别为16.9%和7.0%,两组差异有统计学意义;高LSM组和低LSM组患者肝内复发率分别为28.4%和10.3%,两组差异有统计学意义。3、(1)单因素分析,HCC射频消融后发生LTP的影响因素有肿瘤大小、邻近较大血管、治疗前行TACE、患者肝功能Child-Pugh分级、肿瘤血流灌注程度、患者肝病类型和肝组织硬度。(2)Cox比例风险多因素分析显示：肿瘤大小、是否邻近较大血管、血流灌注程度和肝组织硬度是HCC射频消融治疗后LTP独立危险因素,其风险比(HR)分别为1.12、1.38、1.59和1.77：HCC射频消融前行TACE是LTP的保护因素,风险比为0.52。结论：1、HCC血流灌注对RFA治疗具有“热沉效应”;2、肝组织硬度测量LSM是HCC消融后发生局部肿瘤进展和肝内复发的影响因素;3、肿瘤大小、是否邻近较大血管、血流灌注程度和肝组织硬度是HCC射频消融后LTP的独立影响因素,有助于采取策略,提高RFA疗效,而RFA前行TACE可有效降低LTP发生率。
[Abstract]:Objective: (1) to investigate the effect of blood perfusion on Hepatocellular carcinoma (HCC) blood perfusion on the parameters of radiofrequency ablation (Radiofrequency ablation, RFA), temperature and thermal field and ablation range, and to explore the mechanism of its influence. (2) study the effect of LSM on the short-term efficacy of HCC radiofrequency ablation (3) analysis of H The risk factors of local tumor progression after CC radiofrequency ablation provide a basis for further optimization of the treatment strategy. Materials and methods: Part 1: 62 cases of HCC patients were treated by ultrasound guided RFA in No.302 Hospital in December September 2013, with 66 lesions, all the lesions were guided by ultrasound guided biopsy pathology or more than two kinds of increase. Strong imaging diagnosis. The standard of the group was: (1) the tumor was less than 5cm or 3 or less, the maximum diameter was less than 3cm; (2) no blood vessels, bile duct embolization and extrahepatic metastasis; (3) liver function Child-Pugh A or B grade; (4) patients refused surgical treatment or no surgical resection indication; (5) plasma prothrombin time less than 25 seconds, prothrombin activity of more than 40%, thrombocytopenia Number more than 50 x 109/L; (6) patients volunteered to sign informed consent. Ultrasound contrast (CEUS) and quantitative analysis were performed on HCC lesions. According to the area of the curve (AUC), the lesions were divided into low blood flow perfusion group and high blood flow perfusion group. When RFA, the related treatment parameters included output power, tissue impedance and time of treatment were recorded, treatment simultaneously. Real-time temperature monitoring was performed at 0.5cm (T1) and 1.0cm (T2) at the ablation electrode. After all the lesions completed the radiofrequency ablation energy 25KJ, the long axis diameter (LAD), the short axis diameter (SAD) and the ablation area volume (Volume) of the ablation area were measured immediately after the radiofrequency ablation of 25KJ, and the relationship between the degree of blood flow perfusion with RFA treatment parameters and the range of ablation was studied. The effect of HCC perfusion on the temperature and thermal field of RFA. Second part: 114 lesions were performed in 106 patients with ultrasound guided RFA therapy in September 2013 -2015. All lesions were diagnosed by ultrasound guided biopsy pathology or more than two enhanced imaging. The degree of liver tissue hardness was measured by FibroScan detector (L SM), using 17.5kPa as the critical value, the patients were divided into high LSM group and low LSM group. The difference between two groups of lesions in technical efficiency (TER) and local tumor progression (LTP) was analyzed. The third part: 107 lesions of 99 HCC patients with 302 lines of ultrasound guided RFA from September 2012 to October 2015, all lesions were guided by ultrasound guided tissue All patients had complete CEUS perfusion parameters, LSM test of liver tissue hardness, and average follow-up time of 10.6 months. The risk factors of local tumor progression after RFA treatment in HCC patients were studied by means of single factor analysis and Cox proportional risk multivariate analysis. Draw the survival curve. Results: 1, (1) HCC blood flow perfusion degree and RFA average output power, action time is linear positive correlation, and the linear negative correlation with tissue impedance; (2) low blood flow perfusion group HCC temperature measurement point T1, T2 are higher than the high blood flow perfusion group, two groups of differences have unified significance; (3) HCC perfusion degree and RFA treatment energy for 25KJ elimination The long axis diameter LAD, the short axis diameter SAD and the ablation volume Volume have linear negative correlation, the relationship is y=-0.18 x 10-3x+3.2711 (r=-0.662, p=0.00), y=-0.21 * 10-3x+2.9988 (r=-0.765, p=0.00) and y=-0.0031x+15.892. The efficiency is 94.4% and 95.3% respectively. There is no statistical difference between the two groups, respectively: The progression rate of HCC local tumor in high LSM group and low LSM group was 16.9% and 7% respectively. The difference between the two groups was statistically significant. The recurrence rate of the liver in the high LSM group and the low LSM group was 28.4% and 10.3%, respectively, and the two groups were statistically significant.3, (1) the single factor analysis, the influence factors of LTP after HCC radiofrequency ablation were tumor size, adjacent to larger vessels, treatment TACE, patients with liver function Child-Pugh classification, tumor blood perfusion, liver disease type and liver tissue hardness. (2) multiple factor analysis of Cox ratio risk showed that tumor size, adjacent larger blood vessels, blood flow perfusion and liver tissue hardness were independent risk factors of LTP after HCC radiofrequency ablation, and the risk was 1.12, respectively, (HR). TACE is a protective factor for LTP before 1.38,1.59 and 1.77:HCC radiofrequency ablation, and the risk ratio is 0.52. conclusion: 1, HCC blood perfusion has "heat sink effect" for RFA treatment; 2, liver tissue hardness measurement LSM is the influencing factor of local tumor progression and intrahepatic recurrence after HCC ablation; 3, tumor size, adjacent to larger vessels and blood perfusion process Degree and liver tissue hardness are independent factors of LTP after radiofrequency ablation of HCC. It is helpful to adopt strategies to improve the efficacy of RFA, while TACE before RFA can effectively reduce the incidence of LTP.
【学位授予单位】：中国人民解放军医学院
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R735.7;R445.1

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