对巨大肝癌进行术前放射治疗的探讨

Preoperational Radiotherapy of Massive Hepatocellular Carcinoma

目的:探讨不能切除巨大肝癌经术前放射治疗缩小后切除的新途径.方法:术前放射治疗采用曾认为对肝癌疗效欠满意的放疗技术加以改良为全肝移动条野照射、缩野技术和分段放疗,放射总量达50～60 Gy,放疗后3～4周,肝癌缩小后切除.结果:1987年6月～2000年12月,经放射治疗不能切除巨大肝癌84例,缩小后入选12例二步切除.此12例肝癌经术前放疗后,肿瘤最大径由11～18 cm(中位14 cm)缩小为6～8 cm(中位7 cm);CT显示肝门淋巴结转移灶2 cm、癌旁多个卫星病灶1～3 cm各1例经放疗后病灶消失;1例 AFP转阴者病理仍发现有存活的肝癌细胞.无手术死亡.未见放射性肝炎或术后严重并发症.随访:放射剂量＜50 Gy者3例术后6～10月复发死亡;＞50 Gy者生存1年以上9例(75.0%),3年以上5例(41.6%),5年以上4例(33.3%),10年以上3例(25.0%),17年以上1例仍健在.结论:术前放疗采用全肝移动条野照射、缩野技术和分段放疗是不能切除巨大肝癌的缩小后切除的新途径.采用放射剂量50～60 Gy,放疗后3～4周手术可能比较适宜,远期随访结果令人鼓舞.

Objective：To explore the new approach to cytoreduction by preoperational radiotherapy and sequential resection for unresectable massive hepatocellular carcinoma（HCC）. Methods：Preoperational radiotherapy, patients with surgically verifiable unresectable HCCs during comprehensive therapy underwent cytoreduction, consisting of whole liver moving strip-field radiation with diminished field technology, and split course as a modification from traditional radiotherapy which has been shown to be uneffective for large HCCs. The total irradiated dose was 50 - 60 Gy and the sequential resection was done 3 - 4 weeks post-radiotherapy. Results： From July 1987 to December 2000, 84 cases of varying sizes were reduced from a maximum diameter of 11 - 18 cm（ median sign 14 cm） to 6 - 8 cm（ median sign 7 cm） after treatment with cytoreduction radiotherapy. 12 patients （14. 3% ） were chosen to have hepatectomy. In two cases the computerized tomography （CT） scan revealed complete disappearance of tumor after radiotherapy, including one case with a 2 cm portal lymph node metastases and another case with several 1 - 3 cm satellites lesions around the primary tumor. In addition, one other case of HCC associated with elevated AFP had a conversion to negative Alpha-fetoprotein （AFP） following radiotherapy. There was no operative death, serious postoperative complication or sign of radiation hepatitis. Follow-up ： 3 cases with dosess less than 50 Gy relapsed and died within 6 - 10 months after sequential resection. Of eases above 50 Gy, all patients survived beyond 1 year：9 （ one-year survival of 75% ）. 5 beyond 3 years （ 3 year-survival of 41.6% ） ,4 beyond 5 years （ 5-year survival of 33.3% ） ,3 beyond 10 years （10-years survival of 25 % ） , and 1 was still living after 17 years and in good health. Conclusion： Preoperational radiotherapy, the combination of whole liver moving strip field radiation, diminished field technology and split course is an effective new approach to eytoreduetion and sequential resection 3 - 4 weeks post-radiotherapy, with a total irradiated dose of 50 - 60 Gy safely given pre-operatively. The survival rates reported in this study were very encouraging.