可切除肝细胞癌合并门静脉癌栓的外科治疗

背景与目的 对于肝细胞癌（HCC）合并门静脉癌栓（PVTT）患者而言，手术切除率低，复发率高，预后较差，其治疗方式目前仍有很多争议。笔者总结可切除HCC合并PVTT的外科治疗经验，比较手术与肝动脉化疗栓塞术（TACE）对此类患者的近远期疗效。方法 回顾性分析云南省临沧市人民医院2016年3月—2021年3月收治的39例可切除HCC合并PVTT患者的临床资料，其中23例患者施行手术治疗（手术组），16例行TACE治疗（TACE组）。比较两组患者的相关临床资料与预后，并分析影响患者预后的因素。结果 手术组除1例肿瘤广泛侵犯仅取材活检，其余均完成手术，无手术死亡；19例示切缘阴性；2例术后肝功能不全，经人工肝及其他支持治疗痊愈出院。TACE组16例肝动脉超选、灌注、栓塞顺利；1例因肝动脉完全栓塞，术后3 d因急性肝衰竭救治无效死亡。手术组8例术后辅助TACE治疗，5例靶向治疗，其中1例I型PVTT患者手术后联合TACE等治疗后仍生存47个月。TACE组13例多次治疗，4例给靶向药物，其中1例II型PVTT患者TACE术后经过7次灌注化疗及栓塞仍然生存25个月。与TACE组比较，手术组住院时间延长、医疗成本增加、术后行TACE的例数更少、术后未做其他治疗的例数以及术后AFP恢复正常的例数更多（均P<0.05）。手术组与TACE组的中位生存期分别为16.2个月与9.5个月；0.5、1、2、3年生存率分别为65.2%、43.5%、34.8%、17.4%与46.7%、33.3.0%、13.3%、0。两组患者中位生存期与累积生存率差异均有统计学意义（均P<0.05）。单因素分析结果显示，PVTT分型、甲胎蛋白（AFP）水平、肿瘤大小、肿瘤数目与患者术后生存时间有关（均P<0.05）；多因素分析结果显示，治疗方式、PVTT分型、肿瘤直径、AFP水平是患者术后生存时间的独立影响因素（均P<0.05）。结论 PVTT分型、肿瘤直径、AFP水平直接影响HCC合并PVTT患者的术后生存，外科手术切除治疗效果明显好于TACE治疗，尤其是对于可切除HCC合并I/II型PVTT的患者，但治疗选择可能受患者意愿、经济因素等的限制。

Experience in surgical treatment of resectable hepatocellular carcinoma complicated with portal vein carcinoma thrombus

Background and Aims For patients with hepatocellular carcinoma (HCC) and portal vein tumor thrombus (PVTT), the surgical resection rate is low and the recurrence rate is high, resulting in poor prognosis. Its treatment method is still controversial. In this paper, the authors summarize the experience of surgical treatment of resectable HCC combined with PVTT, and compare the short- and long-term efficacy of surgery and transcatheter arterial chemoembolization (TACE) for these patients.Methods The clinical data of 39 patients with resectable HCC and concomitant PVTT treated from March 2016 to March 2021 were retrospectively analyzed. Of the patients, 23 cases underwent surgical treatment (surgery group) and 16 patients were treated with TACE (TACE group). The main clinical variables and prognosis were compared between the two groups of patients, and the influencing factors for the prognosis of patients were analyzed.Results In surgery group, except one patient who had extensive tumor invasion and only underwent tissue sample removal for biopsy, surgery was completed in all the remaining patients, without surgical death; 19 patients had negative surgical margins; 2 patients developed postoperative liver failure, and were cured and discharged after treatment with artificial liver support and supportive measures. In TACE group, the super-selection, perfusion and embolization of the hepatic arteries were uneventfully performed in all the 16 patients; 1 patient died of acute liver failure 3 d after TACE due to the complete embolization of the hepatic artery. In surgery group, 8 underwent adjuvant TACE after operation and 5 patients received targeted therapy, one of whom with type I PVTT still survived for 47 months after postoperative treatment such as TACE. In TACE group, 13 patients underwent repeated treatment and 4 patients received targeted therapy, one of whom with type II PVTT undergoing 7 times of interventional perfusion chemotherapy and embolization still survived for 25 months. In surgery group compared with TACE group, the operative time was prolonged, the medical cost was increased, the number of cases undergoing postoperative TACE was decreased, and the numbers of cases without any other postoperative treatment and cases whose postoperative AFP level returned to normal were increased (all P<0.05). The median survival time was 16.2 months for surgery group and 9.5 months for TACE group, and the 0.5-, 1-, 2- and 3-year survival rates were 65.2%, 43.5%, 34.8% and 17.4% for surgery group, and 46.7%, 33.3.0%, 13.3% and 0 for TACE group, respectively. There were significant differences in median survival time and accumulate survival rate between the two groups (both P<0.05). Results of univariate analysis showed that PVTT classification, AFP level, tumor size, tumor number were related to postoperative survival time of patients (all P<0.05). Results of multivariate analysis revealed that treatment mode, PVTT classification, tumor diameter and AFP level were independent influencing factors for postoperative survival time (all P<0.05).Conclusion PVTT classification, tumor diameter and AFP level can directly affect the survival of patients with HCC and PVTT. The efficacy of surgical resection is significantly better than that of TACE, especially for those with resectable HCC and type I/II PVTT. However, the treatment choice may be limited by the patient''s will and economic factors.