聚乙烯醇微粒末梢性化疗栓塞肝细胞癌合并肝动静脉分流的疗效与安全性

Analysis of efficacy and safety of terminal chemoembolization with polyvinyl alcohol for hepatocellular carcinoma with hepatic arteriovenous shunts

目的探讨采用聚乙烯醇（PVA）联合化疗药物（或碘油化疗乳剂）对肝细胞癌合并肝动静脉分流（HAVS）患者行末梢性化疗栓塞的疗效与安全性。方法回顾性分析采用PVA微粒联合化疗药物（或碘油化疗乳剂）行末梢性化疗栓塞治疗的97例HCC合并HAVS患者资料，根据经动脉注入对比剂到门静脉或肝静脉显影时间将HAVS分为快速型（36例）、中速型（40例）和慢速型（21例）。行末梢性化疗栓塞治疗，慢速型、中速型和快速型患者分别选择300—500、501—710及711～1000μmPVA。慢速型及中速型分流患者先用碘油化疗乳剂栓塞，再用适量PVA微粒栓塞；快速型分流患者采用单纯化疗药物溶于对比剂后与PVA微粒一同注入。采用Kaplan．Meier法计算患者生存率，并采用Log—Rank检验比较不同分流速度类型患者的生存期差异。观察术后并发症。结果97例患者中位生存期为281d，6、12、18个月生存率分别为67．0％、37．2％、14．2％。疾病控制率为35．2％（19／54）。疾病控制组中位生存期521d（223—818d），进展组中位生存期281d（125～436d），疾病控制组和进展组的生存期差异有统计学意义（χ2=4．853，P=0．028）。快速型、中速型和慢速型患者的中位生存期分别为211、230、378d，不同分流速度类型患者的生存期差异无统计学意义（χ2=3．20，P=0．20）。不同分流速度类型的分流栓塞程度差异有统计学意义（χ2=22．14，P〈0．01）。190次栓塞治疗后出现Child．PughC级11例次，急性肝功能衰竭1例次，食管胃底静脉曲张破裂出血3例次。术后30d患者病死率为4．1％（4／97），其中3例死于食管胃底静脉曲张破裂出血。结论采用PVA联合化疗药物（或碘油化疗乳剂）对肝细胞癌合并肝动静脉分流患者行末梢性化疗栓塞安全、有效。

Objective To evaluate the efficacy and safety of terminal chemoembolization in hepatocellular carcinoma （HCC） with hepatic arteriovenous shunts （HAVS） by polyvinyl alcohol （PVA） plus chemotherapeutic agents or chemotherapeutic agents lipiodol emulsion （CALE）. Methods The medical records of 97 patients with HCC and HAVS were retrospectively analyzed. HAVS was classified into 3 types according to the timing of visualization of the arterial to venous （A-V） on arteriogram images： slow-flow HAVS （n=36）, intermediate-flow HAVS （n=40） and high-flow HAVS （n=21）. The size of the PVA used was determined by the following scheme： slow-flow HAVS： 300 to 500 p,m; intermediate-flow HAVS： 501 to 710 μm; high-flow HAVS： 711 to 1000 μm PVA. The HCCs with slow-flow and intermediate-flow HAVS were embolized by CALE and PVA, while the High-flow HAVS were treated by PVA with chemotherapeutic agents. Survival curves were calculated by Kaplan-Meier method and compared by Log-Rank test. Postoperative complications were analyzed. Results The median overall survival （OS） was 281 days, and the 6-month, 12-month and 18-month survival rate of 97 patients with HCC and HAVS were 67.0%, 37.2% and 14.2%, respectively. The disease control rate （DCR） was 35.2% （19/54）. In rate of overall survival, there was a statistically significant difference between disease control group[median OS was 521 days（223 to 818 days）] and disease progression group[median OS was 281 days（125 to 436 days）] （X2=4.853, P=0.028）. The median OS of patients with the high-flow type, intermediate-flow type and slow-flow type were 211,230 and 378 days, respectively. There was no statistically significant difference among different HAVS types （X2= 3.20,P=0.20）.The extents of embolization showed statistically significant difference （X2=22.14,P〈0.01） among different HAVS types. The Child-Pugh class C was found in 11 eases, acute liver failure occurred in 1 case, and esophageal variees bleeding happened in 3 cases. The mortality of 30-d was 4.1% （4/97）, and 3 patients died of esophageal gastric varices bleeding. Conclusion It is safe and effective to treat HCC with HAVS by the terminal ehemoembolization therapy with PVA plus chemotherapeutic agents （or CALE）.