经肝动脉化疗栓塞术联合微波消融与重复肝切除术治疗复发性肝细胞癌的效果比较
DOI: 10.3969/j.issn.1001-5256.2022.09.020
Clinical effect of transcatheter arterial chemoembolization combined with microwave ablation versus repeat resection in treatment of recurrent hepatocellular carcinoma
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摘要:
目的 比较经肝动脉化疗栓塞(TACE)联合微波消融(MWA)(TACE-MWA)与重复肝切除术(RR)治疗复发性肝细胞癌(RHCC)的效果。 方法 选取2015年6月1日—2020年9月30日内江市第二人民医院收治的178例RHCC患者,按治疗方式不同分为RR组(n=64例)和TACE-MWA组(n=114)。记录治疗前基线人口学资料、肝功能及肿瘤相关情况等。随访至2021年10月,比较两组患者术后总生存期(OS)和无复发生存期(RFS)。进行基于复发模式(复发时间和肿瘤大小)的亚组分析,并研究预后的影响因素。计量资料两组间比较采用独立样本t检验,计数资料两组间比较采用χ2检验;术后生存率用Kaplan-Meier法,两组间生存差异用Log-rank检验;使用Cox多因素分析方法探寻影响生存的独立危险因素。 结果 多因素分析显示,肿瘤直径、AFP水平、ALT、Alb和复发时间是OS的独立预后因素(P值均<0.05),AFP水平和复发时间是RFS的独立预后因素(P值均<0.05)。对于晚期复发(>2年)的RHCC,RR组与TACE-MWA组之间的中位OS有显著差异(54.0个月vs 36.0个月,χ2=6.171,P=0.013),中位RFS也有显著差异(28.0个月vs 21.0个月,χ2=5.211,P=0.022)。对于肿瘤直径≤5 cm的RHCC,两组的中位OS有显著差异(33.0个月vs 27.0个月,χ2=6.447,P=0.011)。 结论 对于早期复发或肿瘤直径>5 cm的RHCC,RR与TACE-MWA有相似的疗效,但对于晚期复发或肿瘤直径≤5 cm的RHCC,RR应为首选。 Abstract:Objective To investigate the clinical effect of transcatheter arterial chemoembolization (TACE) combined with microwave ablation (MWA) (TACE-MWA) versus repeat resection (RR) in the treatment of recurrent hepatocellular carcinoma (RHCC). Methods A total of 178 patients with RHCC who were admitted to The Second People's Hospital of Neijiang from June 2015 to September 2020 were enrolled, and according to the treatment modality, they were divided into RR group with 64 patients and TACE-MWA group with 114 patients. Baseline demographic data, liver function, and tumor conditions before treatment were recorded, and the patients were followed up to October 2021 to compare postoperative overall survival (OS) time and recurrence-free survival (RFS) time between the two groups. Subgroup analysis based on recurrence pattern (recurrence time and tumor size) was performed, and the influencing factors for prognosis were analyzed. The independent samples t-test was used for comparison of continuous data between groups, and the chi-square test was used for comparison of categorical data; the Kaplan-Meier method was used for postoperative survival rate, the Log-rank test was used for survival difference analysis, and a multivariate Cox regression analysis was used to investigate independent risk factors for survival. Results The multivariate analysis showed that tumor diameter, alpha-fetoprotein (AFP) level, alanine aminotransferase, albumin, and time to recurrence were independent prognostic factors for OS (all P < 0.05), and AFP level and time to recurrence were independent prognostic factors for RFS (both P < 0.05). For RHCC with late recurrence (> 2 years), there were significant differences between the two groups in median OS (54.0 months vs 36.0 months, χ2=6.171, P=0.013) and median RFS (28.0 months vs 21.0 months, χ2= 5.211, P=0.022). For RHCC with a tumor diameter of ≤5 cm, there was a significant difference in median OS between the two groups (33.0 months vs 27.0 months, χ2=6.447, P=0.011). Conclusion RR has a similar clinical effect to TACE-MWA in RHCC with early recurrence or a tumor diameter of > 5 cm, but RR should be the first choice for RHCC with late recurrence or a tumor diameter of ≤5 cm. -
表 1 两组基线资料比较
Table 1. Comparison of baseline data between the two groups
项目 RR组(n=64) TACE-MWA组(n=114) 统计值 P值 年龄(岁) 54.26±8.99 53.27±10.39 t=0.635 0.526 男性[例(%)] 55(85.9) 106(93.0) χ2=2.355 0.104 HBV感染[例(%)] 59(92.2) 103(90.4) χ2=0.169 0.681 TBil(μmol/L) 39.055±13.384 36.738±12.230 t=1.143 0.243 AST(U/L) 66.930±25.791 69.720±29.467 t=-0.633 0.527 ALT(U/L) 70.183±26.244 71.210±31.624 t=-0.221 0.817 Alb(g/L) 38.853±3.910 38.752±5.175 t=0.137 0.891 PLT(×109/L) 177.912±71.565 194.029±66.438 t=-1.510 0.133 INR 1.334±0.189 1.384±0.170 t=-1.723 0.088 肿瘤直径(cm) 5.121±2.709 4.582±2.089 t=1.480 0.171 肿瘤个数[例(%)] χ2=3.383 0.066 单发 49(76.6) 72(68.0) 多发 15(23.4) 42(42.0) AFP[例(%)] χ2=0.387 0.534 >400 ng/mL 25(39.1) 50(43.9) ≤400 ng/mL 39(60.9) 64(56.1) Child-Pugh分级[例(%)] χ2=1.369 0.242 A 47(73.4) 74(64.9) B 17(26.6) 40(35.1) BCLC分期[例(%)] χ2=0.472 0.492 A 48(75.0) 80(70.2) B 16(25.0) 34(29.8) 距离初次切除后的复发时间(年) χ2=0.090 0.764 ≤2 35(54.7) 65(57.0) >2 29(45.3) 49(43.0) 表 2 两组并发症比较
Table 2. Comparison of complications between the two groups
项目 RR组(n=64) TACE-MWA组(n=114) χ2值 P值 轻微并发症(等级Ⅰ/Ⅱ)[例(%)] 发热 21(32.8) 45(39.5) 0.780 0.377 疼痛 23(35.9) 32(28.1) 1.188 0.276 呕吐 13(20.3) 35(30.7) 2.246 0.134 胃肠道反应 14(21.9) 13(11.4) 3.493 0.062 严重并发症(等级Ⅲ/Ⅳ/Ⅴ)[例(%)] 12(18.8) 11(9.6) 3.017 0.082 胆瘘 1(1.6) 0 出血 1(1.6) 0 腹水/胸水 6(9.4) 3(2.6) 肝功能衰竭 4(6.3) 5(4.4) 治疗相关死亡 0 3(2.6) 表 3 影响RHCC患者OS的单因素和多因素分析
Table 3. Univariate and multivariate analysis of OS in patients with RHCC
项目 单因素分析 多因素分析 HR(95%CI) P值 HR(95%CI) P值 性别(男vs女) 0.674(0.359~1.264) 0.219 年龄(>60岁vs ≤60岁) 0.671(0.437~1.031) 0.069 HBV感染(是vs否) 0.712(0.369~1.373) 0.311 肿瘤直径(>5 cm vs ≤5 cm) 1.832(1.228~2.733) 0.003 2.299(1.504~3.513) <0.001 多发肿瘤(是vs否) 0.355(0.234~0.538) <0.001 0.611(0.370~1.007) 0.053 Child-Pugh分级(A vs B) 0.470(0.313~0.706) <0.001 0.693(0.451~1.065) 0.094 BCLC分期(A vs B) 0.424(0.279~0.642) <0.001 1.110(0.662~1.861) 0.691 AFP>400 ng/mL(是vs否) 0.228(0.143~0.362) <0.001 0.368(0.212~0.637) <0.001 TBil(>34.2 μmol/L vs ≤34.2 μmol/L) 1.038(0.694~1.551) 0.856 AST (>40 U/L vs ≤40 U/L) 0.995(0.602~1.646) 0.985 ALT (>40 U/L vs ≤40 U/L) 2.891(1.768~4.727) <0.001 3.395(1.978~5.827) <0.001 Alb (>35.0 g/L vs ≤35.0 g/L) 2.565(1.587~4.146) <0.001 2.824(1.718~4.641) <0.001 复发时间(>2年vs ≤2年) 5.854(3.599~9.522) <0.001 3.098(1.777~5.403) <0.001 治疗方式(RR vs TACE-MWA) 0.682(0.453~1.029) 0.068 表 4 影响RHCC患者RFS的单因素和多因素分析
Table 4. Univariate and multivariate analysis of RFS in patients with RHCC
项目 单因素分析 多因素分析 HR(95%CI) P值 HR(95%CI) P值 性别(男vs女) 0.822(0.486~1.388) 0.463 年龄(>60岁vs ≤60岁) 0.914(0.631~1.324) 0.635 HBV感染(是vs否) 0.853(0.492~1.479) 0.571 肿瘤直径(>5 cm vs ≤5 cm) 1.427(1.037~1.964) 0.029 1.136(0.816~1.581) 0.451 多发肿瘤(是vs否) 0.479(0.339~0.676) <0.001 0.907(0.612~1.344) 0.627 Child-Pugh分级(A vs B) 0.637(0.454~0.894) 0.009 0.771(0.547~1.089) 0.140 BCLC分期(A vs B) 0.467(0.330~0.660) <0.001 0.699(0.468~1.043) 0.080 AFP>400 ng/mL(是vs否) 0.321(0.223~0.461) <0.001 0.533(0.356~0.796) 0.002 TBil(>34.2 μmol/L vs ≤34.2 μmol/L) 1.044(0.757~1.440) 0.792 AST(>40 U/L vs ≤40 U/L) 1.318(0.886~1.961) 0.173 ALT(>40 U/L vs ≤40 U/L) 1.841(1.225~2.767) 0.003 1.382(0.911~2.097) 0.128 Alb(>35.0 g/L vs ≤35.0 g/L) 1.498(1.005~2.231) 0.047 1.142(0.760~1.716) 0.523 复发时间(>2年vs ≤2年) 6.158(4.179~9.076) <0.001 4.327(2.800~6.687) <0.001 治疗方式(RR vs TACE-MWA) 0.757(0.540~1.060) 0.105 -
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