大功率微波与射频消融治疗较大肝癌的近期疗效研究

Comparison of high-powered MWA and RFA in treating larger hepatocellular carcinoma

目的探讨大功率微波消融(microwave ablation,MWA)与射频消融(radiofrequency ablation,RFA)治疗较大肝癌的近期临床疗效及术后复发转移相关危险因素。方法对101例未行其他治疗的原发性肝癌患者中45例(病灶数n=60)行大功率MWA治疗(80～100 W),56例(病灶数n=68)行RFA治疗。肿瘤直径范围为3～8cm,依据肿瘤直径分为两组:肿瘤直径3～<5 cm组及肿瘤直径≥5 cm组。消融后1月行超声造影、增强CT或MRI检查。观察治疗后两组患者肿瘤完全坏死率、局部复发率、并发症、生存情况,随访评价两种手术方式疗效并分析肝癌复发转移的相关危险因素。结果大功率MWA与RFA对于3～<5 cm病灶1次完全坏死率分别为82.6%(38/46)、80.0%(40/50);2次完全坏死率分别为100.0%(46/46)、98.0%(49/50)。MWA与RFA对于≥5cm病灶1次完全坏死率分别为64.3%(9/14)、33.3%(6/18);2次完全坏死率分别为85.7%(12/14)、50.0%(9/18)。MWA与RFA组术后2年总复发率分别为40.0%(18/45)、42.9%(24/56)。MWA与RFA组术后1、2年生存率分别为95.6%(43/45)、86.7%(39/45)及94.6%(53/56)、89.3%(50/56)。两组患者并发症差异无统计学意义(P=0.802)。单因素分析示术后复发转移与肿瘤个数(P=0.025)、术前AFP值(P=0.031)、乙肝HBV-DNA载量(P=0.035)及肿瘤病灶邻近危险区域(P=0.001)有关。多因素分析提示,乙肝HBV-DNA载量(P=0.023)与肿瘤病灶邻近危险区域(P=0.001)是肝癌消融治疗术后复发转移的独立危险因素。结论 MWA治疗较大肝癌的完全坏死率比RFA高,局部复发率比RFA低。肿瘤个数、术前AFP值、患者HBV-DNA病毒载量以及肿瘤病灶邻近危险区域都是肝癌术后复发转移的危险因素,其中后两者是独立危险因素。

Objective To study the efficacy and safety of high-powered microwave ablation（ MWA） versus radiofrequency ablation（ RFA） in treating larger hepatocellular carcinoma（ HCC） and clarify the risk factors of recurrence. Methods One-hundred-and-one untreated patients with hepatitis B virus（ HBV） associated HCC were enrolled. Among them,45 patients with 60 lesions received high-powered MWA（ 80 ～ 100 W） percutaneously,and 56 patients with 68 lesions received RFA. All lesions ranged 3 ～ 8 cm in diameter. Contrast enhanced ultrasound and the contrast enhanced CT or MRI were performed one month after ablation. Local tumor control, distant recurrence,complications and the follow-up index for short-term therapeutic efficacy evaluation were analyzed. Results Complete ablation rate of 3 ～ 5 cm lesions was 82. 6%（ 38/46） for the first ablation and 100. 0%（ 46/46） for the second ablation in MWA group and 80. 0%（ 40/50）,98. 0%（ 49/50） in RFA group. Complete ablation rate of ≥5 cm lesions was64. 3%（ 9/14） and 85. 7%（ 12/14） for the first and second ablations,respectively,in MWA group,and 33. 3%（ 6/18）,50. 0%（ 9/18） in RFA group. Two-year recurrence rate was 40. 0%（ 18/45） in MWA group and 42. 9%（ 24/56） in RFA group. One-year and 2-year survival rates in MWA and RFA groups were 95. 6%（ 43/45）,86. 7%（ 39/45） and 94. 6%（ 53/56）,89.3%（ 50/56）（ P =0. 802）. Univariate analysis showed that risk factors of early recurrence included lesion number（ P = 0. 025）,proximity to a major bile duct（ P = 0. 001）,pre-ablation α-fetoprotein（ AFP） level（ P = 0. 031）and HBV-DNA level（ P = 0. 035）. Multivariate analysis identified HBV-DNA level（ P = 0. 023） and proximity to a major bile duct（ P = 0. 001） as independent prognostic factors. Conclusions High-powered percutaneous MWA has higher complete ablation rate and lower local recurrence rate than RFA in treating larger HCC. Lesion number,proximity to a major bile duct,pre-ablation AFP level and HBV-DNA level are important risk factors causing postoperative HCC recurrence; HBV-DNA level and proximity to a major bile duct are independent prognostic factors.