冷循环射频消融与微波消融治疗肝癌的对照研究及术后肝脓肿分析

发布时间：2018-05-09 13:32

本文选题：肝肿瘤 + 热消融　；参考：《山东大学》2016年博士论文

【摘要】：影像引导的射频消融(Radiofrequency ablation, RFA)和微波消融(Microwave Ablation, MWA)是目前临床上治疗肝癌的主要的热消融方法,自上世纪90年代初射频消融技术应用于临床以来,迅速发展为肝癌局部治疗的一线治疗方法。而随着技术的革新及冷循环电极的应用,微波消融在临床的应用也越来越广泛。对于无法行手术治疗的原发性肝癌或转移性肝癌,射频消融和微波消融均是目前肝癌局部治疗的理想选择,无论其临床疗效还是安全性均已有大宗病例和多中心研究报道。尽管RFA和MWA均为微创治疗,且由于冷循环技术的应用,严重并发症发生率相对较低,但仍有一些严重并发症,如腹腔内出血、肝脓肿、出血、肠穿孔、气胸、种植性转移等。其中,肝脓肿为最常见的主要并发症之一。临床工作中,如何针对性选择最合适的热消融方法并减少并发症对于肝癌的个体化治疗尤为重要,本研究通过回顾性分析临床病例资料,一方面探讨经皮冷循环RFA和MWA治疗≤5cm肝癌的近远期疗效和安全性,另一方面对行热消融的肝肿瘤患者术后肝脓肿情况进行分析,探讨热消融术后肝脓肿的发生率及风险因素。第一部分经皮冷循环射频消融与微波消融治疗≤5cm原发性肝癌的疗效及安全性比较[目的]探讨经皮冷循环射频消融与冷循环微波消融治疗≤5cm原发性肝癌的近远期疗效及安全性差异。[方法]回顾性病例对照研究。收集2006年6月至2011年2月在山东大学齐鲁医院及威海市立医院行冷循环RFA和MWA的原发性肝癌临床资料齐全的病例共224例,男154例,女70例,其中RFA患者108例,MWA患者116例,符合单个肿瘤最大直径≤5cm,或多个肿瘤数目≤3个且单个肿瘤最大直径≤3cm; Child-Pugh分级A或B级；无门静脉癌栓或肝外转移；无严重心肝肾肺疾病；凝血酶原活动度在40%以上；血小板≥50×109/L。采用局部麻醉或局部麻醉+静脉麻醉,行超声或CT引导下经皮穿刺冷循环RFA和MWA,术后至少随访5年,通过增强CT或增强MR检查评估消融效果,比较两组患者局部疗效、近远期生存率及并发症,并分析累积生存率的影响因素。[结果]所有患者均成功应用超声或CT引导的经皮肝穿刺RFA或MWA完成治疗。两组肿瘤完全消融率分别为91.1%VS 94.9%(χ2=0.12,P=0.88)。两组总的局部复发率分别为8.1% VS 10.1%(χ2=0.25,P=0.70)；≤3cm的肿瘤RFA组和MWA组的局部复发率为4.2% VS 5.6%(χ2=0.23,P=0.63),3.1-5cm的肿瘤RFA组和MWA组的局部复发率为22.2% VS 8.3%(χ2=1.80,P=0.08)。两组1、3、5年的无瘤生存率分别为84.3%、39.4%、16.6%,81.2%、40.5%、19.2%(log-rank检验χ2=0.30,P=0.584)；总的累积生存率分别为97.2%、71.4%、41.1%,96.5%、74.2%、52.6%(log-rank检验χ2=0.989,P=0.32)。亚组分析中,≤3cm肝癌患者两组1、3、5年的无瘤生存率分别为86.2%、46.0%、17.1%,80.2%、39.4%、18.2%,(log-rank检验χ2=0.003,P=0.959),累积生存率分别100%、87.3%、54.6%,97.1%、78.5%、52.4%(log-rank检验χ2=0.191,P=0.662)。3.1-5cm肝癌患者两组1、3、5年的无瘤生存率分别为78.2%、20.8%、16.4%,83.4%、44.1%、20.3%(log-rank检验χ2=1.173,P=0.279)。累积生存率分别为97.2%、71.4%、41.1%,96.5%、74.2%、52.6%(log-rank检验χ2=0.989,P=0.32)。RFA组和MWA组严重并发症发生率分别为4.6% VS 2.6%(χ2=0.69,P=0.39)。MWA组的平均住院费用(1.31±0.26万元)要低于RFA组(1.92±0.38万元)(P0.05)。Cox比例风险模型分析显示消融方式、性别、年龄、肝功能Child-Pugh分级、合并肝硬化、特殊部位肿瘤、肿瘤个数、对患者无瘤生存的影响无统计学意义(P0.05),术前行肝动脉化疗栓塞(Transcatheter Arterial Chemoembolization, TACE)、术中与经皮无水酒精注射(Percutaneous Ethanol Injection, PEI)联合对累积生存的影响有统计学意义(P0.05)。[结论]经皮冷循环RFA和MWA对于治疗≤5cm肝癌的局部疗效、远期疗效和安全性均无明显差异,严重并发症发生率均低；对于3.1-5cm肝癌,MWA比RFA治疗获得更长的累积生存时间；术前行TAC E、术中与PEI联合治疗对RFA或MWA术后累积生存率有明显影响；MWA治疗的住院费用要明显低于RFA。第二部分肝肿瘤热消融术后肝脓肿的发生率及风险因素探讨[目的]探讨肝肿瘤行热消融术后肝脓肿发生率及风险因素。[方法]收集行RFA和MWA术共691例患者的临床医学资料,对患者基本特征、肝脓肿的发生率及风险因素进行回顾性分析,并应用t检验及多因素Logistic回归分析术后肝脓肿与风险因素之间的关系。[结果]结果：691例患者行RFA治疗385例次,行MWA治疗306例次,肝脓肿总发生率为1.7%,RFA组与MWA组肝脓肿的发生率分别为1.8%、1.6%,两组间差异无统计学意义(P0.05)。Child-Pugh B、C级(P=0.0486)、患胆道疾病(P=0.0305)、糖尿病(P=0.0344)、第一肝门区肿瘤(P=0.0123)的患者术后肝脓肿发生率分别为4.0%、6.7%、6.5%、13.0%,上述四种因素组的患者与对照组比较差异有统计学意义(P0.05)；与PEI联合治疗组(P=0.0026)肝脓肿的发生率明显低于未与PEI联合治疗组,差异有统计学意义(P0.05)。[结论]肝肿瘤热消融治疗后肝脓肿的总体发生率不高,Child-Pugh B、C级、患胆道疾病、糖尿病、第一肝门区肿瘤是其重要风险因素,选用RFA或MWA治疗对热消融术后肝脓肿形成的影响无差别,与PEI联合治疗有助于降低热消融术后肝脓肿的发生率。
[Abstract]:Radiofrequency ablation (Radiofrequency ablation, RFA) and microwave ablation (Microwave Ablation, MWA) are the main heat ablation methods for the treatment of liver cancer at present. Since the application of radiofrequency ablation technology in the early 90s of the last century, it has rapidly developed into a first-line treatment for local treatment of liver cancer. As well as the application of cold circulatory electrodes, microwave ablation is becoming more and more widely used in clinical applications. For primary liver cancer or metastatic liver cancer that cannot be operated on, radiofrequency ablation and microwave ablation are the ideal choice for local treatment of liver cancer. RFA and MWA are minimally invasive, and the incidence of severe complications is relatively low due to the application of cold circulation technology. But there are still some serious complications, such as intraperitoneal bleeding, liver abscess, bleeding, intestinal perforation, pneumothorax, and implant metastasis. Among them, liver abscess is one of the most common major complications. Appropriate heat ablation and reduction of complications are particularly important for the individualized treatment of liver cancer. In this study, a retrospective analysis of clinical case data was conducted to investigate the near and long term efficacy and safety of percutaneous cold circulation RFA and MWA for the treatment of hepatocellular carcinoma (HCC). On the other hand, the liver abscess in patients with liver tumor after heat ablation was divided. Analysis of the incidence and risk factors of liver abscess after thermal ablation. The first part is the comparison of the efficacy and safety of percutaneous cold cycle radiofrequency ablation and microwave ablation in the treatment of primary hepatocellular carcinoma (5cm). [Objective] to explore the short-term and long term effects and safety differences of percutaneous cold circulatory radiofrequency ablation and cold circulation microwave ablation for the treatment of primary liver cancer (HCC). [Methods] a retrospective case control study was conducted. A total of 224 cases of primary liver cancer were collected from June 2006 to February 2011 in Qilu Hospital of Shandong University and Weihai Municipal Hospital of Shandong University. There were 154 cases of male and 70 women, including 108 cases of RFA and 116 cases of MWA, which accords with the maximum diameter of a single tumor less than 5cm, or multiple swelling. The number of tumors was less than 3 and the maximum diameter of single tumor was less than 3cm; Child-Pugh was A or B grade; no portal vein tumor thrombus or extrahepatic metastases; no serious heart and liver and kidney disease; prothrombin activity was above 40%; platelets more than 50 x 109/L. were treated with local anesthesia or local anesthesia + intravenous anesthesia, and CT guided percutaneous puncture cold circulation RFA and CT guided percutaneous puncture were performed. MWA was followed up for at least 5 years. The ablation effect was evaluated by enhanced CT or enhanced MR examination. The local efficacy, near long-term survival and complications were compared in the two groups, and the factors affecting the cumulative survival were analyzed. [results] all patients were successfully treated with ultrasound or CT guided percutaneous liver puncture RFA or MWA. The total ablation rate of the two groups of tumors. 91.1%VS 94.9% (x 2=0.12, P=0.88). The total local recurrence rates in the two groups were 8.1% VS 10.1% (x 2=0.25, P=0.70), and the local recurrence rate of group RFA and MWA < 3cm was 4.2% VS 5.6% (chi 2=0.23, P=0.63). The local recurrence rate was 22.2% 8.3% (chi square). The survival rates were 84.3%, 39.4%, 16.6%, 81.2%, 40.5%, 19.2% (log-rank test X 2=0.30, P=0.584), and the total cumulative survival rates were 97.2%, 71.4%, 41.1%, 96.5%, 74.2%, 52.6% (log-rank test Chi 2=0.989, P=0.32). Rank test Chi 2=0.003, P=0.959), the cumulative survival rate of 100%, 87.3%, 54.6%, 97.1%, 78.5%, 52.4% (log-rank test, 2=0.191, P=0.662) two group of.3.1-5cm liver cancer patients were 78.2%, 20.8%, 16.4%, 83.4%, 44.1%, 20.3% (log-rank test Chi 2=1.173, P=0.279), respectively. The incidence of severe complications in group 52.6% (log-rank test Chi 2=0.989, P=0.32) and MWA group was 4.6% VS 2.6% (x 2=0.69, P=0.39) in group.MWA (1.31 + 2 thousand and 600 yuan), which was lower than RFA group (1.92 + 3 thousand and 800 yuan) (1.92 + 3 thousand and 800 yuan) (P0.05).Cox proportional hazard model. The effects of sclerotherapy, special site tumor and number of tumors on the survival of the patients were not statistically significant (P0.05). The hepatic artery chemoembolization (Transcatheter Arterial Chemoembolization, TACE) was performed before operation, and the combined effect of intraoperative and percutaneous ethanol injection (Percutaneous Ethanol Injection, PEI) on cumulative survival was statistically significant (P0.05). [Conclusion] there is no significant difference in the local effect, long-term effect and safety of percutaneous cold cycle RFA and MWA for the treatment of 5cm liver cancer, and the incidence of severe complications is low. For 3.1-5cm liver cancer, MWA has a longer cumulative survival time than RFA; TAC E before operation and the cumulative survival rate after operation and PEI combined with PEI in the operation are clear. The hospitalization costs of MWA treatment were significantly lower than the incidence and risk factors of liver abscess after RFA. second liver tumor heat ablation. [Objective] to explore the incidence and risk factors of liver abscess after heat ablation of liver tumors. [Methods] the clinical medical data of 691 patients with RFA and MWA were collected, and the basic characteristics of the patients, liver, liver and liver abscess were collected. The incidence and risk factors of abscess were analyzed retrospectively, and the relationship between liver abscess and risk factors was analyzed by t test and multiple factor Logistic regression. [results] 691 cases were treated with RFA, 385 cases were treated with RFA, 306 cases were treated with MWA, the total incidence of liver abscess was 1.7%, and the incidence of liver abscess in group RFA and MWA group was 1.8, respectively. There was no statistically significant difference between the 1.6%, 1.6% and two groups (P=0.0486), C (P=0.0486), biliary tract disease (P=0.0305), diabetes (P=0.0344), and the first hepatic portal tumor (P=0.0123) in patients with postoperative liver abscess 4%, 6.7%, 6.5%, 13% respectively. The differences in the above four group were statistically significant (P0.05). The incidence of liver abscess in the combined treatment group (P=0.0026) with PEI was significantly lower than that in the non PEI group, and the difference was statistically significant (P0.05). [Conclusion] the overall incidence of liver abscess after heat ablation of liver tumor was not high, Child-Pugh B, C, biliary tract disease, diabetes, and the first hepatic portal tumor were the important risk factors, and RFA or MWA treatment was used. There is no difference in the effect of treatment on the formation of liver abscess after thermal ablation. Combined treatment with PEI can help reduce the incidence of liver abscess after thermal ablation.

【学位授予单位】：山东大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R735.7

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