手术切除与射频消融治疗符合米兰标准的不同肝段多发肝癌的效果分析

目的探讨手术切除与射频消融治疗多发位于不同肝段符合米兰标准肝癌的效果。方法回顾性分析2009年2月-2013年2月在华西医院肝脏外科及肝移植中心行手术切除及射频消融术的多发位于不同肝段的符合米兰标准的158例肝癌患者的临床资料,手术切除110例,射频消融48例。比较两种治疗方法的效果差异。计数资料2组间比较采用χ2检验或Fisher确切检验;计量资料满足正态分布的2组间比较采用t检验,不满足正态分布的2组间比较采用Mann-Whitney U检验;采用Kaplan-Meier分析总体生存率及无瘤生存率,生存率比较采用log-rank检验。采用受试者工作特征曲线(ROC曲线)分析肿瘤分化程度与微脉管侵犯的关系。结果射频消融组患者血红蛋白、Alb较手术切除组低(P值均<0.05),术后住院时间较手术切除组短(P<0.05)。手术切除组与射频消融组患者预后差异无统计学意义(1、3、5年总体生存率分别为94.5%、55.2%、28.8%和83.3%、50.0%、26.5%,χ2=1.161,P=0.281;1、3、5年的无瘤生存率分别为86.4%、42.5%、21.9%和79.2%、37.5%、11.0%,χ2=1.771,P=0.183)。无微脉管侵犯者与有微脉管侵犯的患者预后差异有统计学意义(1、3、5年总体生存率分别为94.6%、59.1%、31.8%和94.1%、33.1%、10.1%,χ2=4.250,P=0.039;1、3、5年无瘤生存率分别为87.1%、48.1%、25.0%和82.4%、17.6%、6.1%,χ2=8.120,P=0.004)。低分化肝癌与非低分化肝癌患者预后差异有统计学意义(1、3、5年总体生存率分别为91.2%、33.7%、4.1%和96.1%、64.5%、39.0%,χ2=19.092,P<0.001;1、3、5年无瘤生存率分别为79.4%、10.3%、3.2%和89.5%、56.6%、31.4%,χ2=25.973,P<0.001)。整块肝肿瘤切除与分开局部切除的1、3、5年总体生存率分别为93.7%、57.7%、29.8%和93.3%、38.9%、23.3%(χ2=1.282,P=0.257),1、3、5年无瘤生存率分别为85.3%、46.0%、23.7%和86.7%、26.7、10.0%(χ2=1.706,P=0.191),二者差异均无统计学意义。手术切除组与射频消融组患者术后并发症无明显差异(χ2=3.088,P=0.079),2组患者在术后30 d内均无死亡。结论对于多发的位于不同肝段的符合米兰标准的肝癌患者,手术切除效果与射频消融效果没有明显差异。在手术切除组,整块切除与分开局部切除的效果无明显差异。肿瘤的微脉管侵犯情况、肿瘤的分化程度对患者的预后存在影响。

Clinical effect of surgical resection versus radiofrequency ablation in treatment of multiple liver cancer in different liver segments meeting the Milan criteria

Objective To investigate the treatment methods for multiple liver cancer in different liver segments meeting the Milan criteria.Methods A retrospective analysis was performed for the clinical data of patients with multiple liver cancer in different liver segments meeting the Milan criteria who underwent surgical resection or radiofrequency ablation in Department of Hepatic Surgery and Liver Transplantation Center,West China Hospital,from February 2009 to February 2013.A totle of 158 patients were divided into surgical resection group(n=110)and radiofrequency ablation group(n=48),and the clinical effect of these two methods was compared.The chi-square test or the Fisher exact test was used for comparison of categorical data between two groups;the t-test was used for comparison of normally distributed continuous data between two groups,and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups;the Kaplan-Meier method was used to analyze overall survival rate and disease-free survival rate,and the log-rank test was used for comparison of survival rates;the receiver operating characteristic(ROC)curve was used to investigate the association of degree of tumor differentiation with microvascular invasion.Results There was no significant difference in prognosis between the surgical resection group and the radiofrequency ablation group(1-,3-,and 5-year overall survival rates:94.5%/55.2%/28.8%vs 83.3%/50.0%/26.5%,χ2=1.161,P=0.281;1-,3-,and 5-year disease-free survival rates:86.4%/42.5%/21.9%vs 79.2%/37.5%/11.0%,χ2=1.771,P=0.183).There was a significant difference in prognosis between the patients without microvascular invasion and those with microvascular invasion(1-,3-,and 5-year overall survival rates:94.6%/59.1%/31.8%vs 94.1%/33.1%/10.1%,χ2=4.250,P=0.039;1-,3-,and 5-year disease-free survival rates:87.1%/48.1%/25.0%vs 82.4%/17.6%/6.1%,χ2=8.120,P=0.004).There was a significant difference in prognosis between the patients with poorly differentiated liver cancer and those with non-poorly differentiated liver cancer(1-,3-,and 5-year overall survival rates:91.2%/33.7%/4.1%vs 96.1%/64.5%/39.0%,χ2=19.092,P<0.001;1-,3-,and 5-year disease-free survival rates:79.4%/10.3%/3.2%vs 89.5%/56.6%/31.4%,χ2=25.973,P<0.001).There were no significant differences between the patients with en bloc resection and those with separate local resection in 1-,3-,and 5-year overall survival rates(93.7%/57.7%/29.8%vs 93.3%/38.9%/23.3%,χ2=1.282,P=0.257)and 1-,3-,and 5-year disease-free survival rates(85.3%/46.0%/23.7%vs 86.7%/26.7/10.0%,χ2=1.706,P=0.191).There was no significant difference in postoperative complications between the surgical resection group and the radiofrequency ablation group(χ2=3.088,P=0.079),and no patient died within 30 days after surgery.Conclusion Surgical resection and radiofrequency ablation have a similar effect in the treatment of multiple liver cancer in different liver segments meeting the Milan criteria.En bloc resection and separate local resection have a similar clinical effect in patients undergoing surgical resection.Microvascular invasion of tumor and degree of tumor differentiation may affect the prognosis of such patients.