射频消融治疗肝癌的并发症及其防治措施

近年来,射频消融(radiofrequency ablation,RFA)治疗肝肿瘤以其微创、安全、疗效可靠而得到医患双方的认可,并已在国内外广泛开展[1].但随着病例数的增多和技术的拓展,其并发症防治问题渐引起重视[2].因此,我们对肝癌行RFA治疗过程中可能出现的并发症要有一个全面、正确的认识和处理.本文根据我们在治疗中所遇到的并发症并结合国内外文献,探讨肝癌RFA治疗中的并发症及其防治措施.     

射频消融治疗肝癌的选择与其联合治疗方式

肝癌的治疗模式已由过去的单一外科转变为以外科切除为主的多学科综合治疗模式.而在多种治疗方法中,以射频消融(radiofrequency ablation,RFA)为代表的局部消融治疗进展迅速,已发展成为继手术切除、经动脉插管化疗栓塞(transcatheter arterial chemoembolization,TACE)之后又一常用的肝癌治疗方法,在肝癌综合治疗体系中发挥重要作用.     

局部消融治疗超适应证范围肝癌的现状

肝癌是常见恶性肿瘤之一,我国肝癌发病率占全世界的54％.肝癌的治疗方法主要有手术切除、肝移植、血管介入疗法、局部消融、放疗、化疗、生物及免疫治疗、分子靶向药物、中医中药等.局部消融术操作简单、安全有效、创伤小,在临床中发挥越来越重要作用.     

射频消融治疗中晚期肝癌的可行性

目的 通过经皮射频消融(RFA)对临床多见的中晚期肝癌治疗方案策略性应用,探讨RFA治疗的可行性.方法 655例非手术适应证的肝细胞癌(HCC)患者行经皮RFA治疗,以其中随访资料完整的中晚期癌92例136个病灶(直径≤7.0cm)为研究对象.RFA前行超声造影(CEUS)检查51例(55.4％);采用优化方案策略行规范化治疗67例(72.8％),规范化方案包括根据CEUS筛选适应证、界定浸润范围以制定根治消融方案,及根据数学方案计算行多灶重叠覆盖消融、2～3支双极针立体定位布针适形消融、血供丰富肝癌采用彩色多普勒超声或CEUS引导经皮阻断荷瘤动脉或经动脉插管化疗栓塞后行RFA.另25例常规RFA治疗.所有患者在RFA后均经西医及中医中药保肝治疗.RFA后1个月用增强CT判断肿瘤早期灭活率,其后每3个月用CT并结合甲胎蛋白检查评价疗效.早期灭活率、局部复发率的比较用x2检验或Fisher精确法检验,生存率计算采用KaplanMeier方法及Log-rank检验.结果 肿瘤早期灭活率为90.4％(123/136),严重并发症2例(2.2％),无相关死亡病例.随访3 ～ 134个月,局部复发率16.9％ (23/136),1、3、5年总生存率分别为83.3％、48.3％、21.9％,中位生存期35个月.分层分析显示,Child-Pugh A级、应用CEUS及采用规范化治疗患者的早期灭活率均明显提高,分别为98.3％、98.％、97.0％;肿瘤直径≤3.0 cm、应用CEUS及规范化治疗患者的局部复发率均减低,分别为5.9％、11.8％、16.4％,与相应对照组比较,差异均有统计学意义(P＜ 0.05).Child-Pugh A级、肿瘤直径≤3.0 cm、应用CEUS及规范化治疗患者的5年生存率更高(P＜ 0.05).结论 证实对直径≤7.0 cm、无主脉管癌栓的中晚期HCC行RFA治疗是可行的治疗方法,尤需重视采取规范化治疗以降低复发率.     

射频消融联合瘤体边缘无水乙醇注射治疗大血管旁肝癌的疗效分析

目的 探讨经皮穿刺射频消融联合瘤体边缘无水乙醇注射治疗大血管旁肝癌的效果.方法 将75例大血管旁肝癌患者分为治疗组和对照组,治疗组38例患者接受经皮穿刺射频消融+无水乙醇注射方法治疗,对照组37例患者接受经皮穿刺射频消融方法治疗.选择肿瘤坏死率、甲胎蛋白水平、局部复发率和中位生存期、累积生存率为评价指标,比较两种治疗方法的效果.组间比较采用t检验或x2检验,生存期、累积生存率采用生存分析法与log-rank检验.结果 治疗组和对照组的肿瘤完全坏死率分别为84.2%,54.1%(P<0.01).治疗后1、3、6,12个月治疗组和对照组患者的甲胎蛋白水平分别为(105.0±35.5)μg/L,(28.4±4.3)pg/L,(58.6±6.7)μg/L、(89.5±12.5)μg/L和(137.2±34.6)μg/L,(84.2±18.4)μg/L、(106.6±20.3)μg/L、(173.7±32.0)μg/L,治疗组明显低于对照组(P<0.05).治疗组和对照组在3、6、12、24个月的局部复发率分别为2.6%、7.9%、13.2%、31.6%和10.8%、21.6%、40.5%、62.1%(P<0.01).治疗组和对照组患者中位生存期分别为(28.0±2.8)个月、(19.0±3.6)个月,6、12、24、36个月的累积生存率分别为84.2%,78.9%、60.5%、31.6%和78.4%、67.6%、37.8%、8.1%.结论 瘤体边缘无水乙醇注射作为经皮穿刺射频消融的补充治疗,可以显著提高大血管旁肝癌的疗效,明显降低局部复发率,提高远期生存率.

Abstract：

Objective To explore the effects of percutaneous transhepatic radiofrequency ablation (PRFA) combined with tumor edge of percutaneous absolute ethanol injection (PEI) on liver cancer adjacent to major blood vessels. Methods Seventy five patients with liver cancer adjacent to major blood vessels were randomly divided into two groups: PRFA+PEI therapy group (38 cases) and PRFA control group (37 cases). Tumor necrosis rate, AFP levels, local recurrence rate, median for survival time and cum survival were used as the evaluation index to evaluate the efficacies of the two methods. Results Tumor necrosis rates of the therapy group and the control group were 84.2% and 54.1 % (P < 0.01), respectively; AFP levels of therapy group and control group at 1, 3,6 and 12 months after treatment were (105.0 ± 35.5) Mg/L, (28.4 ± 4.3)Mg/L, (58.6 ± 6.7) μg/L, (89.5 ± 12.5) μg/L and (137.2 ± 34.6) μg/L, (84.2 ± 18.4) μg/L, (106.6 ±20.3) Mg/L, (173.7 ± 32.0) Mg/L, respectively. The rates of therapy group was significantly lower than of control group. Local recurrence rates of the therapy group and control group were 2.6%, 7.9%, 13.2% and 31.6% vs 10.8%, 21.6%, 40.5% and 62.1% (P < 0.05) at 3,6,12 and 24 months after treatment, respectively.Median for survival time of the therapy group and control group were 28.0 ± 2.8 months and 19.0 ± 3.6months, respectively. Cum survival of the therapy group and control group were 84.2%, 78.9%, 60.5% and 31.6% vs 78.4%, 67.6%, 37.8% and 8.1% (P < 0.05) at 6,12,24 and 36 months after treatment, respectively.Conclusion PEI as a supplementary treatment of PRFA can effectively improve the treatment of liver cancer adjacent to major blood vessels and significantly reduce the local recurrence rate and improve long-term survival rates.     

射频消融联合瘤体边缘无水乙醇注射治疗大血管旁肝癌的疗效分析

Objective To explore the effects of percutaneous transhepatic radiofrequency ablation (PRFA) combined with tumor edge of percutaneous absolute ethanol injection (PEI) on liver cancer adjacent to major blood vessels. Methods Seventy five patients with liver cancer adjacent to major blood vessels were randomly divided into two groups: PRFA+PEI therapy group (38 cases) and PRFA control group (37 cases). Tumor necrosis rate, AFP levels, local recurrence rate, median for survival time and cum survival were used as the evaluation index to evaluate the efficacies of the two methods. Results Tumor necrosis rates of the therapy group and the control group were 84.2% and 54.1 % (P < 0.01), respectively; AFP levels of therapy group and control group at 1, 3,6 and 12 months after treatment were (105.0 ± 35.5) Mg/L, (28.4 ± 4.3)Mg/L, (58.6 ± 6.7) μg/L, (89.5 ± 12.5) μg/L and (137.2 ± 34.6) μg/L, (84.2 ± 18.4) μg/L, (106.6 ±20.3) Mg/L, (173.7 ± 32.0) Mg/L, respectively. The rates of therapy group was significantly lower than of control group. Local recurrence rates of the therapy group and control group were 2.6%, 7.9%, 13.2% and 31.6% vs 10.8%, 21.6%, 40.5% and 62.1% (P < 0.05) at 3,6,12 and 24 months after treatment, respectively.Median for survival time of the therapy group and control group were 28.0 ± 2.8 months and 19.0 ± 3.6months, respectively. Cum survival of the therapy group and control group were 84.2%, 78.9%, 60.5% and 31.6% vs 78.4%, 67.6%, 37.8% and 8.1% (P < 0.05) at 6,12,24 and 36 months after treatment, respectively.Conclusion PEI as a supplementary treatment of PRFA can effectively improve the treatment of liver cancer adjacent to major blood vessels and significantly reduce the local recurrence rate and improve long-term survival rates.     

射频消融在肝细胞癌治疗中的研究进展

近年来,肝细胞癌(HCC)发病率居高不下,而射频消融(RFA)自临床开展以来对HCC的治疗取得了令人瞩目的成绩。此文就RFA治疗HCC的进展作一综述。     

射频消融治疗肝癌较微波凝固疗法更安全

据好医生网7月13日报道，射频消融（RFA）和微波凝固疗法（MCT）是肝细胞癌（HCC）的有效局部治疗手段。但目前还不清楚这两种方法哪个更优异。Beppu等报告的研究提示，RFA治疗HCC的疗效与MCT相当，但更安全。研究纳入430例HCC患者，其中230例采用RFA治疗，200例采用MCT治疗。[第一段]     

小肝癌的手术与微创治疗的现状及研究进展

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高龄原发性肝癌射频治疗疗效分析

目的观察高龄原发性肝细胞癌(HCC)患者射频消融治疗(RFA)疗效及RFA对肝功能及生命质量的影响.方法超声引导RFA治疗的225例HCC患者为本文研究对象;非老年组(年龄≤60岁)109例;老年组(年龄＞60岁)116例中,年龄≥70岁者50例,52.6%(61人)合并其他疾病.治疗前两组病灶大小,肝功能分级均无显著差异.比较两组RFA疗效、生存期、生存率、生命质量变化及对肝功能的影响.结果两组消融成功率,局部肿瘤进展率均无明显差异.平均生存期非老年组为(43.31±3.16)个月,老年组为(41.07±2.50)个月,两组无统计学差异.老年组RFA治疗前后生命质量得分无显著差异;治疗后,老年组社会功能领域得分高于非老年组,两组生命质量总得分及其他领域得分均无显著差异.两组患者治疗前与治疗后1个月的谷丙转氨酶、谷草转氨酶、总胆红素水平均无明显差异.结论RFA对不适合手术治疗的高龄HCC患者,可获得良好疗效,并保持患者较高的生命质量;对高龄患者可作为首选治疗方法之一.     

肝癌的介入治疗

肝癌是临床常见的恶性肿瘤，以手术治疗（包括肝移植）效果最佳。由于肝癌在起病初期较隐匿，当临床诊断明确时，受肿瘤大小、部位及肝功能等因素的影响，仅20％～30％的患者尚有手术机会，而化疗对肝癌治疗效果甚微。近年来，介入治疗以其创伤小、效果佳在临床逐渐得到重视。介入治疗主要包括经皮穿刺肝癌热凝固疗法、冷冻疗法、乙醇注射及放射性粒子置入内照射术，经肝动脉介入的动脉栓塞、放射性微球内照射及栓塞化疗术等。这些姑息疗法，在改善患者生活质量及预后的同时，有的还为手术治疗创造了时机。     

肝细胞肝癌外科治疗方法的选择

2008年9月底制定了肝细胞肝癌外科治疗方法的选择,全文如下.     

肝癌的早期治疗

原发性肝癌发病率居世界恶性肿瘤第五位，每年新增人数约100万，死亡约60万。近年来随着影像技术及分子生物学的发展，肝癌的早期治疗也取得了长足进步。[第一段]     

肝癌的非手术治疗

肝癌患者病情复杂,宜根据病变的具体情况和各种治疗方法的不同特点和适应证选择最佳方案。治疗方法的选择应依据肿瘤的大小和数目、肿瘤侵袭的部位和范围、静脉癌栓和远处转移情况、患者肝功能代偿程度以及全身状况(年龄、心肺功     

肝癌综合介入治疗的现状

原发性肝癌恶性程度很高，大多数患者就诊时已无外科手术指征，即使能进行外科手术切除，术后肿瘤复发率亦较高。采用肝动脉插管化疗、栓塞方法（transcatheter arterial chemoembolization，TACE）亦称介入疗法，治疗不能手术切除的肝癌和术后复发的肝癌，取得了良好的效果。介入疗法已被公认为治疗不能手术切除和术后复发肝癌的首选方法，但肝癌介入治疗后复发、转移问题仍未解决，影响了其远期生存率。越来越多的学者认识到对肝癌采用综合介入治疗的必要性和重要性。     

原发性肝癌化疗的挑战与机遇

原发性肝细胞癌（HCC）目前外科手术切除仍是提高生存率的主要有效手段。但由于80％以上的HCC手术时往往伴有严重的肝功能不全、肝内播撒和远处转移，手术切除率低，且手术后复发率高，故综合治疗（包括占重要地位的系统性化疗）一直是被公认的治疗模式。     

肝移植治疗原发性肝癌

目的评价原位肝移植治疗原发性肝癌的疗效和受体选择,探讨原位肝移植在原发性肝癌治疗中的作用和地位.方法回顾性分析1999年1月至2005年2月完成的9 2例原发性肝癌肝移植患者的临床资料.结果原发性肝癌肝移植92例,根据国际抗癌协会的国际癌症病期分类（TNM）,Ⅰ期8例,ChildPugh均为A级;Ⅱ期13例,Child-Pugh A级11例、B级2例;Ⅲ期12例,Child-Pugh A级8例、B级3例、C级1例;Ⅳ期59例,Child-Pugh A级52例、B级5例、C级2例.手术成功75例,成功率81.5%,围手术期死亡17例,病死率18.5%.随访6～68个月,最短生存40 d,最长无瘤生存68个月,肿瘤最短51 d复发,生存时间3年以上的7例患者至今仍无瘤生存.Ⅰ期：1年生存者5例,2年生存者3例,3年生存者2例,5年生存者1例;Ⅱ期：1年生存者6例,2年生存者2例,3年生存者2例;Ⅲ期：1年生存者3例,无生存超过2年者;Ⅳ期：1年生存者18例,2年生存者5例,3年生存者3例,5年生存者1例.Ⅰ、Ⅱ期的生存率显著高于Ⅲ、Ⅳ期.术后出现原发性肝癌复发35例,总复发率为46.7%.Ⅰ、Ⅱ、Ⅲ、Ⅳ期的复发率分别为12.5%、0、50.0%和47.5%,Ⅲ、Ⅳ期的复发率明显高于Ⅰ、Ⅱ期.结论不同期原发性肝癌肝移植术后的生存情况差别较大,肝移植治疗早期原发性肝癌效果显著,进展期原发性肝癌由于移植效果差应持慎重态度.     

Ablation of hepatocellular carcinoma

Radiofrequency ablation (RFA) has gained a wide acceptance as a first-line therapeutic option for small hepatocellular carcinoma (HCC). For very early-stage HCC, despite a higher rate of local tumour progression, RFA is considered as a viable alternative to surgical resection owing to its comparable long-term survival, reduced morbidity, and greater preservation of hepatic parenchyma. For HCCs larger than 2 cm, RFA can contribute to near-curative therapy when combined with chemoembolization. RFA can be used as part of a multimodal treatment strategy for more advanced or recurrent cases, and could be a useful bridging therapy for patients who are waiting for liver transplantation. However, the use of RFA is still limited in treating large tumours and some tumours in high-risk locations. To overcome its current limitations, other ablation techniques are being developed and it is important to validate the role of other techniques for enhancing performance of ablation therapy for HCC.