微波消融联合动脉化疗栓塞治疗原发性肝癌合并门静脉分支癌栓的疗效分析

发布时间：2018-06-09 01:05

本文选题：肝癌 + 门静脉癌栓　；参考：《第二军医大学》2017年硕士论文

【摘要】：研究背景和研究目的原发性肝癌是一种常见的恶性肿瘤。每年新增患者人数及死亡人数居高不下,肝癌细胞恶性程度高,进展快,侵袭性强,发现较晚。大多数患者发现时已处于中晚期。原发性肝癌发展为中晚期的一项重要特征就是癌细胞侵袭性生长入门静脉,形成门静脉癌栓。一旦形成门静脉癌栓后,患者预后差,若无治疗,生存期一般仅为3-6个月。门静脉癌栓通常由门静脉分支向主干侵袭,主干癌栓形成后易造成肝功能损害,顽固性腹水,食管胃底静脉曲张破裂出血等。而目前尚没有十分有效的治疗门静脉癌栓的方法。EASL指南认为索拉非尼治疗是唯一的手段。本研究针对原发性肝癌侵犯门静脉分支但尚未侵犯门静脉主干的患者,通过两种治疗原发性肝癌合并门静脉癌栓的方法:单纯TACE治疗及TACE联合微波消融治疗进行对比研究,以期待能够改善这类患者的预后,为原发性肝癌侵犯门静脉分支的治疗提供一些新思路。研究方法本研究收集2014年1月至2014年12月曾在上海东方肝胆外科医院住院治疗的145例原发性肝癌伴门静脉分支癌栓患者的临床资料进行回顾性研究。以72例接受TACE联合门静脉分支癌栓微波消融治疗的患者为治疗组,以73例单纯行TACE治疗的患者为对照组。生存期随访及资料收集截止时间为2016年12月31日。通过对两组患者的近期疗效、生存时间及并发症等进行对比分析,研究两组治疗效果有无差异,进一步对计数资料用百分率表示,组间率采用卡方检验;影响OS的单因素、多因素分析采用COX回归分析,生存率采用Kaplan-Meier曲线法及log-rank检验,并发症及不良反应等分类资料采用卡方检验,P0.05认为差异有统计学意义。结果1、两组患者癌栓稳定率DCR的比较治疗组术后1个月癌栓稳定率DCR为94.4%;对照组DCR为91.8%,P0.05。治疗组术后3个月癌栓稳定率DCR为86.1%;对照组DCR为68.5%,P0.05。治疗组术后6个月癌栓稳定率DCR为68.1%;对照组DCR为38.4%,P0.05。3个月及6个月两组患者癌栓稳定率DCR比较,有统计学意义。2、两组患者生存时间比较治疗组及对照组中位生存期分别为16.4个月和11.3个月,两组间比较差异有统计学意义(P0.05)。对所有患者按照癌栓分型进行生存期分析,I型癌栓患者58例,中位生存时间为16.6个月;II型癌栓患者共87例,中位生存时间为14.3个月。不同癌栓分型生存时间有统计学差异(P=0.019)。治疗组中,对不同癌栓类型生存期进行分析,I型癌栓28例,中位生存期为19.4个月;II型癌栓44例,中位生存期为16.4个月。两组总体生存期P=0.417。提示无明显统计学差异。共纳入的145例患者中,初诊发现为I型癌栓者共58例,治疗组28例,中位生存时间为19.4个月;对照组30例,中位生存时间为16.6个月,两组生存期比较无统计学差异(P=0.291)。初诊发现为II型癌栓共87例,治疗组44例,中位生存时间16.4个月;对照组43例,中位生存时间为9.7个月,两组生存期比较有统计学差异(P=0.000)。3、通过分析发现,PMWA治疗、AFP水平、癌栓分型、原发灶最大直径和肿瘤数目是单独影响两组患者生存期的主要因素。再把所有单因素纳入多因素COX分析模型,进行比较发现,是否经PMWA治疗、癌栓分型、肿瘤数目和原发灶最大直径是影响患者生存时间的相对独立因素。其中经PMWA治疗是保护因素,II型癌栓、肿瘤数目3个和肿瘤最大直径5cm是危险因素。说明门静脉癌栓经PMWA治疗可以降低这类患者死亡风险,患II型门静脉癌栓、肿瘤数目3个和肿瘤最大直径5cm可增加这类患者死亡的风险。4、两组患者不良反应的比较两组患者不良反应为发热、局部肝区疼痛、恶心呕吐、转氨酶升高、总胆红素升高等,未见统计学差异。治疗组术后并发症出现胆道热损伤1例,消化道出血1例,动静脉瘘形成2例;对照组术后并发症出现肿瘤破裂出血1例,消化道出血1例,胆囊炎1例,穿刺点血肿1例。可能提示分支门静脉癌栓经PMWA治疗是一种较为安全的治疗手段。结论1、对于原发性肝癌合并门静脉分支癌栓的患者,动脉化疗栓塞TACE联合微波消融PMWA治疗相比单纯行动脉化疗栓塞TACE治疗,对延缓门静脉癌栓由分支向主干侵犯进程有一定效果,达到为肿瘤治疗的降期目的,给这类病人赢得更多的治疗机会。2、对于原发性肝癌合并门静脉分支癌栓的患者,动脉化疗栓塞TACE联合微波消融PMWA治疗相比单纯行动脉化疗栓塞TACE治疗,可以延长患者生存期。3、微波消融PMWA联合动脉化疗栓塞TACE治疗相比单纯TACE治疗,没有产生更多的不良反应及并发症,是一种相对安全的治疗手段。
[Abstract]:Primary hepatocellular carcinoma (HCC) is a common malignant tumor. The number of newly added patients and death toll is high, the malignant degree of liver cancer is high, the progression is fast, and the invasiveness is strong. Most patients are found in the middle and late stages. The development of primary liver cancer is an important feature of the middle and late stages of cancer. Once the portal vein tumor thrombus is formed, the prognosis is poor and the survival time is only 3-6 months. The portal vein tumor thrombus is usually attacked by the portal vein to the main trunk, the main stem tumor thrombus is easily caused by the liver function damage, the intractable ascites, the esophagogastric varices bleeding and bleeding. But there is no very effective treatment for portal vein thrombus at present. The.EASL guide believes that Sola Fini therapy is the only means. This study is aimed at patients with primary liver cancer that invade the portal vein but have not yet violated the portal vein. Two methods of treatment for primary liver cancer with portal vein tumor thrombus are treated by simple TACE treatment and TACE Combined with microwave ablation, we hope to improve the prognosis of these patients and provide some new ideas for the treatment of portal vein branch of primary liver cancer. This study collected 145 cases of primary liver cancer hospitalized in Shanghai Oriental Hepatic Surgery Hospital from January 2014 to December 2014. The clinical data of patients with tumor thrombus were reviewed. 72 patients received TACE combined with portal vein branch thrombus microwave ablation were treated as the treatment group, and 73 patients treated with TACE were treated as the control group. The survival time follow-up and data collection cut-off time were in December 31, 2016. The short-term efficacy, survival time, and survival time of the two groups of patients were compared. The results of the complications were compared and analyzed. There were no differences in the treatment effect between the two groups. The percentage of the count data was further expressed, the rate of inter group was checked by chi square test, the single factor affecting the OS, the multiple factor analysis using the COX regression analysis, the survival rate using the Kaplan-Meier curve method and the log-rank test, and the complications and adverse reactions. The difference was statistically significant in the P0.05 test. Results 1, the stability rate of the tumor thrombus in the two groups was 94.4% in the comparison group 1 months after operation, 91.8% in the control group and 91.8% in the control group, and 86.1% in the P0.05. group 3 months after the operation. The DCR in the control group was 68.5%, and the cancer thrombus stability in the P0.05. treatment group was 68.1% after the operation for 6 months, and 68.1%. In group DCR of 38.4%, P0.05.3 months and 6 months, the stability of cancer thrombus was compared with DCR, with a statistically significant.2. The median survival time of the two groups was 16.4 months and 11.3 months in the comparison group and the control group, respectively. The difference between the two groups was statistically significant (P0.05). The survival period of all patients was analyzed according to the tumor thrombus classification. There were 58 patients with type I tumor thrombus, with a median survival time of 16.6 months; a total of 87 patients with type II tumor thrombus, with a median survival time of 14.3 months. The survival time of different type of tumor embolus was statistically different (P=0.019). In the treatment group, the survival time of different type of tumor embolus was analyzed, 28 cases of type I tumor thrombus, the median survival period of 19.4 months, 44 cases of II type tumor thrombus and middle birth. The survival period was 16.4 months. There were no significant statistical differences in the total survival time of the two groups. Of the 145 patients, the first diagnosis was found in 58 cases of type I tumor thrombus, 28 in the treatment group and 19.4 months in the median survival time; 30 cases in the control group, with a median survival time of 16.6 months, and no statistical difference in the survival period of the two groups (P=0.291). The first diagnosis was found. There were 87 cases of type II tumor thrombus and 44 cases in the treatment group, with a median survival time of 16.4 months, and 43 cases in the control group with a median survival time of 9.7 months. The two groups had a statistical difference (P=0.000).3. The analysis found that the PMWA treatment, the AFP level, the tumor thrombus type, the maximum diameter of the primary focus and the number of tumors were the main factors affecting the survival period of the two groups of patients. Factors. All single factors were included in the multifactor COX analysis model. It was found that PMWA treatment, tumor emboli, the number of tumors and the maximum diameter of the primary focus were the relative independent factors affecting the patient's survival time. The PMWA therapy was a protective factor, the II type tumor thrombus, the 3 tumor number and the tumor maximum diameter 5cm were the risk factors. PMWA treatment can reduce the risk of death in this type of patients with portal vein tumor thrombus, II type of portal vein tumor thrombus, 3 tumor number and the maximum tumor diameter 5cm can increase the risk of death in this type of patients, the two group of patients with adverse reactions are two groups of patients with fever, local liver pain, nausea and vomiting, elevated aminotransferase, total bile. There were 1 cases of biliary tract heat injury in the treatment group, 1 cases of gastrointestinal bleeding, 2 cases of arteriovenous fistula formation, 1 cases of hemorrhage and hemorrhage in the control group, 1 cases of hemorrhage in the digestive tract, 1 cases of cholecystitis and 1 cases of puncture point hematoma in the control group, which could suggest that the PMWA treatment of the branch portal vein tumor thrombus is a more effective method. Conclusion 1, for patients with primary liver cancer with portal vein branch tumor thrombus, arterial chemoembolization TACE combined with microwave ablation PMWA treatment compared with pure action pulse chemoembolization TACE treatment, to postpone the portal vein tumor thrombus from the branch to the main course of invasion of the process has certain effect, to achieve the goal of the tumor treatment of this kind of reduction. Patients won more opportunities for treatment,.2, for patients with primary liver cancer with portal vein branch tumor thrombus, arterial chemoembolization TACE combined with microwave ablation PMWA therapy can prolong the patient's survival.3 compared with pure action pulse chemotherapy embolization TACE, and microwave ablation PMWA combined with arterial chemoembolization TACE treatment compared with pure TACE therapy, It is a relatively safe treatment to produce more adverse reactions and complications.
【学位授予单位】：第二军医大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R735.7

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