应用射频消融法对肝肿瘤患者进行规范化治疗

Standard treatment of liver malignancies with radiofrequency ablation

目的探讨射频消融(RFA)规范化治疗及综合措施对提高肝肿瘤疗效的应用价值。方法302例计476个肝脏恶性肿瘤行RFA治疗,应用规范化治疗方案及附加治疗方法,总结疗效。原发性肝癌(HCC)181例,282个癌灶,肿瘤大小平均4.2cm。肝转移癌(MLC)121例,194个癌灶,肿瘤大小平均3.9cm。根据肿瘤大小、形态及邻近膈肌、胆囊、胃肠等不同位置,采用相应的规范化方案及个体化方案相结合治疗;重视相邻重要结构区域的消融布针方法及操作技巧;应用辅助定位、局部注水、加强肿瘤血管消融等附加方法综合治疗。结果综合应用以上方法,RFA后1个月增强CT或超声造影显示肿瘤灭活率HCC为95.7%(270/282),MLC为94.8%(184/194);邻近肠管肿瘤为91.1%(51/56),邻近膈肌肿瘤为88.5%(69/78),邻近胆囊肿瘤为94.3%(49/52)。随访3～57个月,局部复发率HCC为10.3%(29/282),MLC为14.4%(28/194)。患者1年、2年、3年的生存率HCC为87.6%、67.4%、58.6%;其中50例Ⅰ～Ⅱ期肝癌的生存率分别为90.7%、85.9%、73.7%。MLC为87.4%、48.2%、25.3%。并发症占2.2%(13/583);分别为出血5例,采用局部消融、全身用药等处理措施;肠穿孔1例,对邻近肠管肿瘤采用治疗后延长禁食时间等措施进行预防。余7例为邻近脏器结构轻度损伤,无与射频治疗相关死亡。结论采用规范化RFA治疗方案及适宜的个体化治疗方案,重视附加方法的应用,有助于提高肝肿瘤灭活率;掌握主要并发症的类型及对应预防措施,是提高疗效及推广RFA治疗的重要环节。

Objective To investigate the role of standard treatment with ultrasound-guided radiofrequency ablation (RFA) in improving the treatment level of liver malignancies. Methods 302 patients with 476 liver malignancies were treated with established protocol and adjuvant measures and subjected to efficiency analysis. In the 302 patients, 181 had 282 hepatocellular carcinomas (HCC) with a mean diameter of 4.2 cm, and 121 had 194 metastatic liver carcinomas (MLC) with a mean diameter of 3.9 cm. According to UICC-TNM system 50 patients (27.6%) were in stage I/II and 131 (72.4%) in stage III/IV (including 39 patients with recurrent HCC after surgical resection). A standard protocol and an individualized protocol were used to treat the tumors based on their size, shape and special location such as the distance from diaphragm, gallbladder and gastrointestinal tract. Needle placement method and operation skill for the tumor region adjacent to important structures were described. Some adjuvant measures such as supplementary fine needle localization, local saline injection and feeding vessel ablation were used to improve RFA efficacy in tumors with different features. Local ablation of bleeding site and haemostatic administration systemically were adopted to deal with bleeding. For the patients with tumor adjacent to gastrointestinal tract, prolonged fasting after the RFA procedure was required. the patients were followed up regularly to assess the treatment efficiency, and the tumor was considered complete necrosed if no viability was found on enhanced CT or enhanced US one month after RFA. Results The tumor necrosis rate was 95.7% (270 / 282 tumors) for HCC, 94.8% (184 / 194 tumors) for MLC, 91.1% (51 / 56 tumors) for tumor near gastrointestinal tract, 88.5% (69 / 78 tumors) for tumors near diaphragm, and 94.3% (49 / 52 tumors) for tumor near gallbladder. The local recurrence rate was 10.3% (29 / 282 tumors) for HCC and 14.4% (28 /194 tumors) for MLC. The 1, 2 and 3 year overall survival rates were 87.6%,67.4% and 58.6% in the HCC patients, and 87.4%, 48.2%, 25.3% in the MLC patients respectively. The 1, 2 and 3 year survival rates of 50 HCC patients in early (I-II) stages were 90.7%,85.9% and 73.7%, respectively. The incidence of complications was 2.2% (13 / 583 sessions), including 5 cases of hemorrhage, 1 case colon perforation, 8 cases of injury of adjacent structures. Conclusion Application of proper protocol and adjuvant measures plays an important role in improving tumor ablation rate. Knowledge about possible complications and their control may increase the treatment efficacy and help to promote the use of RFA technique.