以手术为主的系列疗法治疗原发性大肝癌(附191例报告)

目的 探讨以手术为主的系列疗法治疗原发性大肝癌的方法及疗效。方法 手术治疗原发性大肝癌191例，其中行各类肝切除术121例，行深度冷冻治疗70例。术中配合全植入式输药器（IDDS）植入，手术前后配合经导管肝动脉化疗栓塞术（TACE）、无水酒精注射（PEI）、生物免疫治疗和中医中药治疗。以CT动脉造影CTA）、动脉期CT门脉造影（CTAP）作为早期发现卫星灶的方法，并以外周血AFP mRNA监测肿瘤的转移复发。术前肝功能评价采用Child分级配合BCAA／AAA。结果 切除组1，3，5年生存率分别为75．8％、45．6％和30．4％。冷冻组1，3年生存 率分别为63．2％和37．0％。手术死亡率为1．6％。AFPmRNA阳性者复发率为69．2％，阴性者复发率为33．3％，二者间差异有显著性（P＜0．05）。手术死亡者BCAA／AAA均＜1．5。结论 以手术为主的系列疗法对原发性大肝癌有良好疗效，应成为大肝癌治疗的主要策略。外周血AFPmRNA与肝癌复发有关，有望成为新的临床指标。BCAA／AAA加Child分级可更为准确地评价术前肝脏储备功能。

A surgery oriented serial treatments of 191 patients with large primary liver cancer

OBJECTIVE: To discuss the methods and effects of a series of surgery oriented therapies in the treatment of large primary liver cancers. METHODS: From January 1993 to June 1999, 191 patients with large liver cancer were treated chiefly by operation. The size of the primary cancer varied from 5.2 to 19.7 cm (median 9.4 cm). Various kinds of liver resections were performed in 121 patients and, as a supplement, deep cryosurgery was carried for out the rest 70 patients. Importable drug delivery system (IDDS) was instituted intraoperatively. Transcatheter arterial chemo-embolization (TACE, THP 30-60 mg, E-ADM 20-40 mg, CDDP 40-80 mg, MMC 10-20 mg, iodine oil 5-30 ml), percutaneous ethanol injection (PEI), bioimmunotherapy and the traditional Chinese medicine were used pre- and post-operatively. CT angiography (CTA) and CT during arterial portography (CTAP) were used to find satellite nodules. Early recurrence was diagnosed by AFPmRNA monitor in peripheral blood. Child's classification plus branch chain amino acid/aromatic amino acid (BCAA/AAA) were adopted in evaluating the pre-operative liver functions. RESULTS: Remarkable results were observed after this surgery oriented serial treatment. The 1-, 3- and 5-year survival rates in the resection group were 75.8%, 45.6% and 30.4%, respectively. The 1- and 3-year survival rates in the cryosurgery group were 63.2% and 37.0%. The operative mortality was 1.6%. Recurrence rates were 69.2% in AFPmRNA positive group and 33.3% in AFPmRNA negative group. Comparing this two groups, significant difference was observed (P < 0.05). BCAA/AAA were lower than 1.5 in two patients died after resection. CONCLUSION: A serial treatment with surgery as the chief modality gives satisfactory results in large primary liver cancers. This regimen should be adhered to as a main strategy in dealing with large liver cancers. AFPmRNA in the peripheral blood, signifying a recurrence, may become a hope of a new clinical parameter. BCAA/AAA plus Child's classification is able to evaluate more accurately the hepatic functional reserve before surgery.