卵巢癌肝转移患者的手术疗效及影响预后因素分析

Analysis on curative effect and prognostic factors of hepatectomy for hepatic metastasis in patients with ovarian cancer

目的探讨卵巢癌肝转移患者肝部分切除手术疗效及影响预后的因素。方法回顾性分析2001年1月至2011年12月在中山大学附属第一医院和中山大学附属第三医院手术治疗的38例卵巢癌肝转移患者，患者均签署知情同意书，符合医学伦理学规定。其中同时性肝转移21例，行卵巢肿瘤细胞减灭术（CRS）及同期肝部分切除术（CRS＋同期肝切除组）；异时性肝转移17例，行Ⅱ期肝部分切除术（Ⅱ期肝切除组）。肝叶切除方式包括不规则肝切除24例，肝左外叶切除7例，肝左叶切除5例，肝右叶切除2例。观察术中出血量、术中输血量、术后并发症、死亡等情况；比较CRS＋同期肝切除组和Ⅱ期肝切除组的术中出血量及输血量；术后随访，观察患者存活情况；收集卵巢癌原发肿瘤分化程度、转移灶发现时间、转移灶数目、转移灶直径及转移灶有否包膜等相关临床病理资料，进行影响预后因素分析。两组术中出血量及输血量比较采用t检验，采用Life—Table法计算累积存活率，采用Log—rank检验比较存活率差异。结果38例患者手术均获成功，CRS＋同期肝切除组术中出血量（530±55）ml，术中输血量（457±33）ml；Ⅱ期肝切除组术中出血量（340±35）ml，术中输血量（227±22）ml。两组出血量及输血量比较，差异均有统计学意义（均为P〈0．05）。无手术死亡病例。术后并发症主要为一过性低蛋白血症和中到大量腹水，经支持治疗和对症处理后均缓解，痊愈出院。38例均获得随访，随访中位时间17个月（8～50个月），卵巢癌肝转移肝切除术患者1年和2年存活率分别为58％（22例）和40％（15例），平均生存期13个月。原发肿瘤分化程度、转移灶发现时间、转移灶数目、转移灶直径及转移灶有否包膜与术后1年、2年存活率相关（均为P〈0．05）。结论卵巢癌肝转移行同期肝切除或Ⅱ期肝切除术均是安全的，临床疗效良好。原发灶肿瘤分化程度、转移灶发现时间、转移灶数目、转移灶直径及转移灶有否包膜是影响预后的主要因素。

Objective To investigate the impact and prognostic factors of partial hepatectomy on hepatic metastasis in patients with ovarian cancer. Methods Thirty-eight patients with hepatic metastasis of ovarian cancer in the First and the Third Affiliated Hospital of Sun Yat-sen University from January 2001 to December 2011 underwent hepatectomy. Among them, 21 cases with synchronous liver metastases underwent ovary cytoreductive surgery （CRS） and partial liver resection simultaneously （CRS plus liver resection group）. The other 17 cases with metachronous liver metastasis underwent partial liver resection in 3 to 12 months later （CRS plus later liver resection group）. Surgical resection included 24 cases of irregular hepatectomy, 7 cases of left lateral lobectomy, 5 cases of left lobeetomy, 2 cases of right lobectomy. Blood loss during operation, intraoperative blood transfusion, postoperative complications and mortality were observed. The amount of intraoperative bleeding and blood transfusion were compared between the CRS plus liver resection group and CRS plus later liver resection group. All these patients were followed up and the survival rate was observed. Clinical pathological data of ovarian cancer with liver matastasis such as histological type, grade of differentiation, onset time, the number of loci, diameter and capsule of metastasis tumor were collected and analyzed to define prognostic factors. The amount of intraoperative bleeding and blood transfusion were compared between two groups by statistical method of t test. Life-Table was used to calculate the cumulative survival rate and Long-rank test to compared the difference of survival rate. Results The operations were successfully performed in 38 patients. The average intraoperative blood loss was （530±55）ml and intraoperative blood transfusion was （457±33）ml in CRS plus liver resection group, while the average blood loss and blood transfusion in CRS plus later liver resection group was （340±35）ml and （227±22）ml respectively. There was significant difference between two groups in the amount of blood loss and blood transfusion （all in P〈0.05）. There was no operation death case. The major postoperative complications were transient hypoalbuminemia and moderate to massive ascites. Patients recovered by supportive and symptomatic treatment. Thirty-eight patients were followed up from 8 to 50 months with median follow-up period 17 months. The 1 and 2 year survival rates were 58%（22 cases） and 40%（15 cases）, respectively. The mean survival time was 13 months. Primary carcinoma differentiation degree, onset time, number of metastasis, diameter as well as existence of metastasis capsule were related to 1 and 2 years survival rates （all in P〈0.05）. Conclusions Simultaneous liver resection or CRS plus later liver resection group are both safe and effective for hepatic metastasis of ovarian cancer. The differentiation grade of primary tumor, onset time, number of metastasis, diameter as well as existence of metastasis capsule are the main prognostic factors.