不同治疗模式对不能切除的肝癌二期手术预后的影响

目的探讨不能切除的肝细胞癌(HCC)经皮穿刺肝动脉化疗栓塞(TACE)及经手术肝动脉结扎、置管化疗栓塞(HALCE)缩小后二期切除的疗效,并比较不同治疗模式对预后的影响.方法204例HCC二期切除患者,分成TACE组及HALCE组.TACE组112例,行TACE1～7次(中位2.4).HALCE组92例,其中49例行HALCE,7例行HALCE+肝脏外放射治疗,36例行HALCE+导向内放射治疗.肿瘤缩小后予以切除.选择7个可能对HCC二期切除术后预后产生影响的临床因素通过单因素、多因素Cox模型对预后进行分析.结果随访至1999年6月,首次TACE及HALCE后1、3、5、7年生存率分别为95.7%、69.3%、56.5%及44.5%,切除肿瘤后1、3、5、7年生存率分别为88.5%、64.9%、51.9%及38.3%.TACE组及HALCE组1、3、5、7年生存率分别为94.1%、64.7%、51.2%、40.8%和96.3%、73.9%、61.6%、45.2%,2组差异无显著性意义(P＞0.05).影响预后的主要因素是肝硬化程度和肿瘤坏死程度(P＜0.05).TACE组中肝硬化程度、缩小后肿瘤有无包膜及肿瘤坏死程度是影响预后的主要因素(P＜0.05),而HALCE组各因素对预后影响差异无显著性意义(P＞0.05).结论不能一期切除的HCC缩小后应进行二期切除,且可获得满意疗效.而肝硬化程度、肿瘤坏死程度是影响肝癌二期切除预后的主要因素.

Influence of different treatment modalities on survival of patients with two -stage resection of unresectable hepatocellular carcinoma

OBJECTIVE: To study the therapeutic results of hepatic resection for shrunk hepatocellular carcinoma (HCC) after transcatheter arterial chemoembolization (TACE) and hepatic artery ligation and chemoembolization (HALCE) in patients with unresectable HCC, and compare the influence of the above different treatment modalities on the prognosis. METHODS: Two hundred and four patients w ith pathologically proven HCC by two stage liver resection were classified into two groups: TACE group (n = 112) and HALEC group (n = 92). The patients in the TACE group received a total of 1-7 consecutive treatment courses (average, 2.4 +/- 1.2 courses). HALCE was done in 49 patients. HALCE alternating fractionated radiotherapy was employed in 7 patients and HALCE + targeting regional internal radiotherapy in 36. Shrunk tumors were surgically removed by two-stage operation in all the patients with unresectable HCC. Seven possible factors influencing the results of two-stage resection of HCC were studied. RESULTS: All the patients were followed up to June, 1999. The 1-, 3-, 5-, and 7-year survival rates were 95.7%, 69.3%, 56.5% and 44.5% after the first TACE and HALCE, respectively and 88.5%, 64.9%, 51.9% and 38.3% after resection of the shrunk HCC, respectively. The 1-, 3-, 5- and 7-year survival rates were 94.1%, 64.7%, 51.2% and 40.8% respectively in the TACE group and 96.3%, 73.9%, 61.6% and 45.2% respectively in the HALCE group. There were no statistically differences between the survival rates in the TACE and HALCE groups. The extent of cirrhotic liver and percentage of tumor necrosis were of prognostic significance. In the TACE group, the extent of cirrhotic liver, the percentage of tumor necrosis and whether capsule of shrunk tumor was complete or in complete were of prognostic significance. In the HALCE group, however, the 7 factors were not found to be statistically significant for the prognosis. CONCLUSIONS: Sequential resection should be done after cytoreduction of tumor for the patients with unresectable HCC, which might improve their survival. The extent of cirrhotic liver and the percentage of tumor necrosis after TACE or HALCE are the major factors affecting the survival of patients with two-stage operation.