超声引导射频消融治疗邻近肝表面的原发性肝癌

Clinical application of ultrasound-guided radiofrequency ablation for primary hepatocellular carcinoma near the liver surface

目的探讨超声引导下经皮射频消融（RFA）治疗邻近肝表面原发性肝癌的适应证选择、治疗方案及操作技巧。方法选择经临床和病理确诊的61例原发性肝癌患者的69个邻近肝表面病灶拟行RFA治疗者，经超声造影增强检查后确定符合RFA治疗的适应证。61例患者中，男38例，女23例，平均年龄58．2岁。肿瘤直径（3.8±1．2）cm，肿瘤直径4≥cm的病灶27个（39．1％）。肝功能Child-Pugh分级为A级40例，B级21例。在RFA治疗前采用肿瘤旁腹腔内注射生理盐水、增加穿刺点防止肿瘤表面中心部位过度重叠，并采用多次消融减少针道转移、避免垂直方向进针等附加方法，以提高邻近肝表面肿瘤的灭活效果。结果全组患者的肿瘤早期灭活率为98．6％。由于凝固消融的肝组织面积较小，1周后患者肝功能检查丙氨酸氨基转移酶升高仅为（148．5±38．5）U／ml，并于（1．8±0．6）周内恢复至治疗前水平。甲胎蛋白从1000—1500ng／ml下降至（98．5±42．5）ng／ml，其中13例（21．3％）患者降至正常水平。随访20—61个月，平均25．3个月。肿瘤局部复发率为5．8％（4／69），肝内异位复发率为24．6％（15／61）。全组患者的1、2和3年生存率分别为83．6％、57．3％和44．2％。结论对邻近肝表面原发性肝癌患者行RFA治疗，可采用肝外或在肝脏与腹膜之间注射生理盐水、增加皮肤穿刺点、避免垂直：亨向进针、轻加压状态下消融等方法，减少并发症并提高疗效。该治疗方法创伤小、肝功能损伤小，是原发性肝癌的有效治疗手段之一。

Objective To explore the value of ultrasound-guided percutaneous radiofrequency ablation （RFA） in designing the indication, treatment protocol and operational skills for patients with primary hepatocellular carcinoma （HCC） near the liver surface. Methods Sixty-one HCC patients with 69 lesions, confirmed by clinical examination and pathology, underwent percutaneous radiofrequency ablation. The study included 40 cases of liver function Child-Pugh grade A and 21 cases of grade B. The average size of tumors was （3.8± 1.2） cm, tumor diameter ≥ 4 cm accounted for 39. 1% （27/69 lesions）, and the average age was 58.2 years （range, 35-76 years）. Taking comprehensive measures, such as intraperitoneal injection of saline adjacent to the tumor before RFA, increasing the puncture sites on the surface of tumor to avoid overlapping of the central portion of tumor, repeated ablation of the needle track to reduce needle tract metastasis, avoid vertical puncture, and other additional measures, to improve the inactivation of tumors adjacent to the liver surface. Enhanced CT/MRI was performed to evaluate the curative effect at 1, 3, 6 and 24 months after the treatment. Results The inactivation rate of tumor was 98.6% （68/69 lesions） and local recurrence rate was 5.8%（4/69） after RFA. The tumor-related marker AFP was 1 000-1 500 ng/ml before and reduced to （98.5±42.5） ng/ml after radiofrequency ablation, among them returned to normal in 13 cases （21.3%）. Since the ablation area was rather small, the level of serum alanine aminotransferase was elevated only to （148.5±38.5） U/ml at one week after RFA and returned to normal at （1.8±0.6） week after RFA. No patient experienced severe liver dysfunction. The local HCC recurrent rate after RFA was 5.8%（4/69lesions） and intrahepatic heterotopic recurrence rate was 24.6% （ 15/61 ）. The 20-61 months follow-up showed that the 1-, 2- and 3-year survival rate was 83.6%,57.3% and 44.2%, respectively. Conclusions Ultrasound- guided pereutaneous radiofrequeney ablation provides an effective minimally invasive treatment for primary HCC near the liver surface. Taking some additional measures such as intraperitoneal injection of saline, increase of pereutaneous puncture sites, and avoiding vertical needle puncture, may reduce complications and improve the therapeutic outcome. RFA is one of effective and minimally invasive treatment and causing less liver damage for primary HCC near the liver surface.