三维可视化消融辅助系统在肝细胞癌射频消融术中的应用价值

赫嵘; 贾哲; 蒋力; 张珂

doi:10.3969/j.issn.1001-5256.2022.09.019

三维可视化消融辅助系统在肝细胞癌射频消融术中的应用价值

DOI: 10.3969/j.issn.1001-5256.2022.09.019

首都医科大学附属北京地坛医院普外科，北京 100015

基金项目:

北京市教育委员会科研计划一般项目 (KM201710025026)

伦理学声明：本研究于2017年5月22日通过首都医科大学附属北京地坛医院伦理委员会批准，批号为京地伦科字(2017)第(050)-01号，符合《赫尔辛基宣言》的原则，患者均知情同意。

利益冲突声明：本研究不存在研究者、伦理委员会成员、受试者监护人以及与公开研究成果有关的利益冲突。

作者贡献声明：赫嵘负责课题设计，收集数据，资料分析，撰写论文；贾哲、蒋力参与修改论文；张珂负责拟定写作思路，指导撰写文章并最后定稿。

详细信息

通信作者:
张珂，zhangke302@sina.com

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出版历程
- 收稿日期: 2022-02-09
- 录用日期: 2022-03-23
- 出版日期: 2022-09-20

Application of the three-dimensional visualization ablation planning system in radiofrequency ablation for hepatocellular carcinoma

Department of General Surgery, Beijing Ditan Hospital, Capital Medical University, Beijing 100015, China

Research funding:

The Science and Technology Plan of the Beijing Education Committee (KM201710025026)

More Information

Corresponding author: ZHANG Ke, zhangke302@sina.com(ORCID: 0000-0002-5006-8674)

摘要

摘要: 目的探讨三维可视化消融辅助系统在肝细胞癌射频消融术中应用的意义。方法选取2017年7月—2020年12月于首都医科大学附属北京地坛医院因肝细胞癌行射频消融治疗的患者71例，其中三维组(n=34)术前应用三维可视化消融辅助系统进行射频方案规划，二维组(n=37)术前应用二维影像进行射频方案规划。比较两组患者的一次穿刺成功率、肿瘤完全消融率、无瘤生存期等。计数资料两组间比较选择Fisher精确检验、连续校正的χ²检验或Pearson χ²检验；符合正态分布的计量资料两组间比较采用t检验，非正态分布的计量资料两组间比较采用Mann-Whitney U检验；Kaplan-Meier法绘制生存曲线，Log-rank(Mantel-Cox)检验比较肿瘤复发和生存情况，通过Cox比例风险回归模型分析无瘤生存期的影响因素。结果三维组一次性穿刺成功率(94.12%)高于二维组(75.68%)(Pearson χ²=4.183，P=0.041)，三维组术中穿刺耗时中位时间(5 min)低于二维组(7 min)(Z=-2.407，P=0.013)。三维组和二维组的消融完全率分别为97.06%和91.89%，两组差异无统计学意义(连续矫正χ²=0.183，P=0.669)。在1、2、4年累积无瘤生存率比较中，三维组分别为90.8%、78.8%和72.8%，二维组分别为61.5%、55.9%和44.7%, 两组差异有统计学意义(χ²=5.073，P=0.024)。多因素Cox回归分析结果显示，术前规划方式、消融是否完全、术后1个月AFP水平为肝细胞癌患者射频消融术后无瘤生存期的独立影响因素(P值均＜0.05)。结论通过三维可视化消融辅助系统进行肝细胞癌射频消融规划，可以保证射频消融的疗效，降低肝细胞癌复发率，延长患者的无瘤生存期。
- 癌, 肝细胞 /
- 消融技术 /
- 成像, 三维
Abstract: Objective To investigate the significance of the three-dimensional visualization ablation planning system in radiofrequency ablation for liver cancer. Methods A total of 71 patients who received radiofrequency ablation for hepatocellular carcinoma in Beijing Ditan Hospital, Capital Medical University from July 2017 to December 2020 were enrolled as subjects. The 34 patients in the three-dimensional group used the three-dimensional visualization ablation planning system for radiofrequency protocol planning before surgery and the 37 patients in the two-dimensional group used the two-dimensional image for radiofrequency protocol planning before surgery. The two groups were compared in terms of the indices such as the first-attempt success rate of puncture, complete tumor ablation rate, and tumor-free survival. The Fisher's exact test, the chi-square test of continuous correction, or the Pearson chi-square test was used for comparison of categorical data between two groups; the t-test was used for comparison of normally distributed continuous data between groups, and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between groups. The Kaplan-Meier method was used to plot survival curves, and the Log-rank (Mantel-Cox) test was used for comparison of tumor recurrence and survival; the Cox proportional-hazards regression model analysis was used to investigate the influencing factors for tumor-free survival. Results Compared with the two-dimensional group, the three-dimensional group had a significantly higher first-attempt success rate of puncture (94.12% vs 75.68%, Pearson χ²=4.183, P=0.041) and a significantly shorter median time of puncture (5 minutes vs 7 minutes, Z=-2.407, P=0.013). There was no significant difference in complete ablation rate between the three-dimensional group and the two-dimensional group (97.06% vs 91.89%, continuous correction χ²=0.183, P=0.669). There were significant differences in the 1-, 2-, and 4-year cumulative tumor-free survival rates between the three-dimensional group and the two-dimensional group (90.8%/78.8%/72.8% vs 61.5%/55.9%/44.7%, χ²=5.073, P=0.024). The multivariate Cox regression analysis showed that preoperative planning method, complete or incomplete ablation, and alpha-fetoprotein at 1 month after surgery were independent influencing factors for the tumor-free survival of patients with liver cancer after radiofrequency ablation (all P < 0.05). Conclusion Radiofrequency ablation planning via the three-dimensional visualization ablation planning system can ensure the therapeutic effect of radiofrequency ablation, reduce the recurrence rate of liver cancer, and prolong the tumor-free survival of patients.
- Carcinoma, Hepatocellular /
- Ablation Techniques /
- Imaging, Three-Dimensional

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图 1 三维可视化消融辅助系统对肝癌RFA的术前规划

注：a, 二维影像显示肿瘤信息；b, 选择合适消融范围及穿刺路径；c, 三维重建下肿瘤及消融球覆盖范围；d, 模拟超声影像；e, 消融球与周围血管关系；f, 射频针在体表穿刺的位置；g, 射频针与矢状面、水平面、冠状面的角度信息。

Figure 1. Preoperative planning of the radiofrequency ablation for HCC with the three-dimensional visualization ablation planning system

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图 2 三维可视化消融辅助系统对肝S6段肿瘤RFA术前规划及术后效果评价

注：a, 二维影像显示肿瘤；b, 二维影像下选择射频路径和范围; c, 三维重建下消融球与穿刺路径; d, 模拟超声影像；e, 射频针与矢状面、冠状面、水平面的角度信息；f, RFA术中超声影像；g、h, 术后1个月复查实际消融范围。

Figure 2. Preoperative planning and postoperative outcomes of the radiofrequency ablation of the tumor in the S6 of the liver use the three-dimensional visualization ablation planning system

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图 3 三维可视化消融辅助系统在肝S7段两枚肿瘤RFA的术前规划和术后评价

注：a、b, 肝S7段两枚肿瘤；c、d, 二维影像下选择消融范围及穿刺路径; e、f, 三维重建下显示消融范围、穿刺路径及消融球与周围血管关系；g、h, 术后1个月复查显示实际消融范围。

Figure 3. Preoperative planning and postoperative outcomes of the radiofrequency ablation of two tumors in the S7 of the liver use the three-dimensional visualization ablation planning system

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图 4 两组间无瘤生存率的比较

Figure 4. The comparison of the tumor free survival between the tow groups

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图 5 两组间总生存率的比较

Figure 5. The comparison of the overall survival between the tow groups

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表 1 两组间一般资料比较

Table 1. Baseline characteristics between the two groups

项目	三维组(n=34)	二维组(n=37)	统计值	P值
性别[例(%)]			χ²=0.265	0.607
男	24(70.59)	24(64.86)
女	10(29.41)	13(35.14)
年龄(岁)	58.53±9.22	58.43±8.22	t=0.047	0.963
乙型肝炎(是/否，例)	28/6	28/9	χ²=0.474	0.491
肝硬化(是/否，例)	26/8	31/6	χ²=0.599	0.439
Child-Pugh评分	5(5~6)	5(5~6)	Z=-0.144	0.885
MELD评分	8(7~9)	8(7~10)	Z=-0.557	0.578
术前白细胞计数(×10⁹/L)	4.74±1.81	4.47±1.53	t=0.678	0.500
术前血小板计数(×10⁹/L)	111.50(70.93~138.25)	113.00(67.90~163.50)	Z=-0.242	0.809
术前ALT(U/L)	25.20(14.65~35.77)	22.00(17.05~31.50)	Z=-0.121	0.904
术前TBil(μmol/L)	15.15(11.98~18.73)	13.10(10.70~18.55)	Z=-0.771	0.441
术前Alb(mg/L)	162.39±55.74	162.29±61.90	t=0.007	0.995
术前INR	1.12(1.04~1.19)	1.13(1.07~1.25)	Z=-0.720	0.472
术前AFP(ng/mL)	10.35(3.05~59.65)	6.50(2.47~40.83)	Z=-0.852	0.394
肿瘤数量(1/2/3，个)	28/5/1	34/1/2		0.172
肿瘤最大径(cm)	1.60(1.40~2.50)	1.90(1.50~2.40)	Z=-1.085	0.278
手术方式[例(%)]			χ²=3.408	0.065
经皮射频	22(64.7)	31(83.8)
经腹腔镜射频	12(35.3)	6(16.2)
术后白细胞计数(×10⁹/L)	7.62±2.92	6.81±2.95	t=1.168	0.247
术后血小板计数(×10⁹/L)	96.85(69.25~127.28)	98.40(73.50~150.70)	Z=-3.222	0.747
术后ALT(U/L)	106.45(59.23~169.95)	78.00(49.20~137.60)	Z=-1.209	0.227
术后TBil(μmol/L)	19.10(15.13~25.83)	18.80(15.85~25.20)	Z=-0.150	0.881
术后前白蛋白(mg/L)	127.02±54.00	139.42±58.82	t=-0.923	0.359
术后INR	1.21(1.14~1.29)	1.19(1.10~1.32)	Z=-0.466	0.641
术后并发症分级(无/Ⅰ/Ⅱ/ⅢA/ ⅢB/ⅣA/ⅣB, 例)	30/2/2/0/0/0/0	29/5/2/1/0/0/0		0.588
术后1个月AFP(ng/mL)	3.90(2.65~9.85)	4.08(2.14~8.39)	Z=-0.357	0.721

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表 2 影响无瘤生存期的单因素Cox比例风险回归分析

Table 2. Univariable Cox proportional hazard models of the tumor free survival

项目	SE	Wald值	自由度	P值	B值
术前规划方式	0.573	3.997	1	0.046	0.318
是否合并乙型肝炎	0.317	4.697	1	0.030	1.987
肿瘤最大径	0.388	4.761	1	0.029	0.429
消融完全	0.574	10.092	1	0.001	0.161
术后1个月AFP	0.003	9.880	1	0.002	1.010

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表 3 影响无瘤生存期的多因素Cox比例风险回归分析

Table 3. Multivariable Cox proportional hazard models of the tumor free survival

项目	SE	Wald值	自由度	P值	B值	95%CI
术前规划方式	0.504	3.905	1	0.048	0.369	0.138~0.992
消融完全	0.651	11.462	1	0.001	0.110	0.031~0.395
术后1个月AFP	0.002	9.635	1	0.002	1.006	1.002~1.009

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