TIPS序贯TACE、靶向和/或免疫治疗BCLC D期原发性肝细胞癌伴严重门静脉高压并发症

目的 观察TIPS序贯TACE、靶向和/或免疫治疗巴塞罗那临床肝癌（BCLC）D期原发性肝细胞癌（HCC）伴严重门静脉高压并发症的效果。方法 回顾性分析20例BCLC D期HCC伴严重门静脉高压并发症患者，均首先接受TIPS，之后序贯接受TACE、靶向和/或免疫治疗，观察治疗效果、并发症和预后。结果 20例TIPS均获成功，18例术中以弹簧圈或联合组织胶栓塞曲张静脉。TIPS前门体压力梯度为（32.25±4.51）mmHg，术后（18.05±7.54）mmHg，较术前降低（P<0.01），门静脉高压症状均得到有效缓解；未见手术相关并发症及围手术期死亡。术后1个月功能状态（PS）评分较术前降低（P<0.01）；17例肿瘤分期下降，其中14例降至BCLC C期、2例降至BCLC B期、1例降至BCLC A期。后续11例接受靶向治疗，接受TACE联合靶向治疗、TACE联合靶向及免疫治疗、靶向联合免疫治疗各3例。随访0~26个月，期间均未出现消化道出血，难治性腹腔积液均明显改善；未出现肝性脑病或分流道再狭窄。Kaplan-Meier生存曲线显示，术后3、6、12和24个月累积生存率分别为73%、61%、35%和4%。结论 TIPS序贯TACE、靶向和/或免疫治疗BCLC D期原发性HCC伴严重门静脉高压并发症安全、有效。

TIPS sequential TACE, targeting and/or immunotherapy for BCLC stage D primary hepatocellular carcinoma with severe portal hypertension complications

Objective To observe the effect of TIPS sequential TACE, targeting and/or immunotherapy in treatment of Barcelona clinic liver cancer (BCLC) stage D primary hepatocellular carcinoma (HCC) with severe portal hypertension complications. Methods Data of 20 patients with BCLC stage D HCC and severe portal hypertension complications were retrospectively analyzed. TIPS was first given to all 20 patients, then TACE, targeted, and/or immunotherapy were used according to patients'' circumstances. The therapeutic effect, complications and prognosis were observed. Results TIPS was successfully completed in all 20 patients, while simultaneous coil or tissue glue embolization of the gastric veins was performed in 18 cases. The pressure difference between portal vein and inferior vena cava was (32.25±4.51) mmHg before TIPS and (18.05±7.54) mmHg after TIPS, the latter were less than the former (P<0.01). The symptoms of portal hypertension effectively alleviated after TIPS, and no surgical related complications nor perioperative death occurred. The functional status (PS) score 1 month after TIPS was lower than that before TIPS (P<0.01). The tumor stage decreased in 17 cases, including 14 cases to BCLC stage C, 2 cases to BCLC stage B and 1 case to BCLC stage A. Targeted therapy was given to 11 patients after TIPS, while 3 patients underwent TACE combined with targeted therapy, 3 patients underwent TACE combined with targeted and immunotherapy and 3 patients underwent targeted combined immunotherapy. During 0 to 26 months'' following-up, no gastrointestinal bleeding occurred, and the symptoms of intractable ascites greatly relieved, no hepatic encephalopathy nor shunt restenosis was found. Kaplan-Meier survival curve showed that the cumulative survival rates at 3, 6, 12 and 24 months was 73%, 61%, 35% and 4%, respectively. Conclusion TIPS sequential TACE, targeting and/or immunotherapy for primary HCC of BCLC stage D with severe portal hypertension complications was safe and effective.