化疗栓塞治疗肝癌合并肝动-静脉分流的预后因素分析

Polyvinyl alcohol chemoembolization for the treatment of hepatocellular carcinoma associated with hepatic arteriovenous shunt: analysis of prognostic factors

目的探讨聚乙烯醇(PVA)联合碘油化疗药乳剂(或化疗药物)在肝癌合并肝动-静脉分流栓塞治疗的生存预后因素。方法 2013年1月—2014年6月,97例肝癌并肝动-静脉分流的患者(慢速型分流21例,中速型分流40例,快速型分流36例),分别应用PVA-300、PVA-500及PVA-700行末梢性化疗栓塞,其中慢、中速型加用碘油化疗乳剂栓塞,快速型仅加用化疗药物。应用Kaplan-Meier法、Log-Rank检验进行生存分析,Cox比例风险模型进行多因素回归分析。结果 97例肝癌合并肝动-静脉分流的患者中位生存期为281 d,6、12、18个月生存率分别为67%、37.2%、14.2%。多因素分析结果显示:术前AFP≥400 ng/ml(HR=3.763,P=0.002)、门静脉癌栓形成(HR=2.669,P=0.021)及疾病进展(HR=2.55,P=0.039)为独立危险因素;而栓塞次数≥3次(HR=0.216,P=0.001)、分流完全及次全栓塞(HR=0.22,P=0.030)及采用综合治疗(HR=0.181,P<0.001)为独立保护因素。结论 PVA联合碘油化疗药乳剂(或化疗药物)末梢性化疗栓塞肝癌合并肝动-静脉分流是一种可行、有效的方法。栓塞次数较多、分流完全、次全栓塞以及采用综合治疗的患者预后较好,而术前AFP高水平、门静脉癌栓形成及疾病进展为患者预后危险因素。

Objective To analyze the survival prognostic factors in patients with hepatocellular carcinoma（HCC） complicated by hepatic arteriovenous shunts（HAVS） who were treated with chemoembolization by using polyvinyl alcohol（PVA） together with iodine oil chemotherapeutic emulsion（or chemotherapeutic agents）. Methods From January 2013 to June 2014, a total of 97 HCC patients associated with HAVS were admitted to authors＇ hospital to receive interventional chemoembolization. The HAVS patterns included slow- flow shunt type（n=21）, moderate- flow shunt type（n=40） and fast- flow shunt type（n=36）.PVA- 300, PVA- 500 and PVA- 700 were separately used for peripheral chemoembolization; additional iodine oil chemotherapeutic emulsion was employed for patients with slow- flow shunt type and moderate- flow shunt type HAVS, and only chemotherapeutic agent was added to patients with fast- flow shunt type HAVS. The prognostic factors were retrospectively analyzed by using univariate Kaplan- Meier method, Log- Rank test,and a Cox proportional hazards model was used for multivariate regression analysis. Results The median survival time of the 97 HCC patients associated with HAVS was 281 days, with the 6- month, 12- month and18- month survival rates being 67%, 37.2% and 14.2% respectively. Multivariate analysis results indicated that preoperative AFP le vel ≥400 ng/ml（HR =3.763,P =0.002）, formation of portal vein tumor thrombus（HR=2.669,P=0.021） and disease in progress（HR=2.55,P=0.039） were the independent risk factors; and the independent protection factors included ≥3 times of embolization procedure（HR =0.216,P =0.001）,complete and sub- complete occlusion of HAVS（HR =0.22,P =0.030） and use of comprehensive treatment（HR =0.181,P 0.001）. Conclusion For the treatment of HCC associated with HAVS, percutaneous interventional chemoembolization by using polyvinyl alcohol（PVA） together with iodine oil chemotherapeutic emulsion（or chemotherapeutic agents） is clinically feasible and effective. For patients who have received ≥3times of embolization procedure and comprehensive therapies, and their shunts have been completely or subcompletely obstructed, the prognosis is usually better; while the preoperative AFP level ≥400 ng/ml（HR=3.763,P =0.002）, the formation of portal vein tumor thrombus（HR=2.669,P =0.021） and the disease in progress（HR=2.55,P=0.039） are the independent risk factors.