肝细胞癌合并不同类型脉管癌栓的手术疗效分析

Surgical effect analysis of hcpatocellular carcinoma with different lymphovascular invasion

目的：比较肝细胞癌合并门静脉癌栓、肝静脉癌栓和胆管癌栓的临床特征和手术疗效，分析各种癌栓分型及不同癌栓手术方式对患者预后的影响。方法：采用回顾性横断面研究方法。收集2004年1月至2014年12月广西医科大学附属肿瘤医院收治的220例肝细胞癌合并脉管癌栓患者的临床资料。220例患者中，肝细胞癌合并门静脉癌栓 140例，肝细胞癌合并肝静脉癌栓 36例，肝细胞癌合并胆管癌栓 44例。根据患者具体情况行肿瘤联合癌栓切除术、肿瘤切除＋脉管切开癌栓取出术或仅行癌栓取出术。观察指标：（1）肝细胞癌合并门静脉癌栓、 肝静脉癌栓和胆管癌栓患者的临床特征比较。（2）手术及术后情况。（3）随访和生存情况。采用门诊和电话方式进行随访，了解患者术后生存情况。随访时间截至2015年12月。正态分布的计量资料以±s表示，3者间比较采用单因素方差分析，两者间比较采用t检验。计数资料比较采用x2检验。采用Kaplan-Meier法绘制生存曲线并计算生存率，Log-rank检验进行生存分析。结果：（1）肝细胞癌合并门静脉癌栓、 肝静脉癌栓和胆管癌栓患者的临床特征比较：肝细胞癌合并门静脉癌栓患者肝功能Child-Pugh分级A级和B级、腹腔积液、肿瘤直径、有肿瘤包膜分别为133例和7例、23例、（10±4）cm、91例，肝细胞癌合并肝静脉癌栓患者分别为35例和1例、4例、（9±4）cm、27例，肝细胞癌合并胆管癌栓患者分别为35例和9例、16例、（6±4）cm、15例，3者上述指标比较，差异均有统计学意义（x2=12.693，10.408，F=11.300， x2=17.188，P〈0.05）。（2）手术及术后情况：140例肝细胞癌合并门静脉癌栓患者中，51例行肿瘤联合癌栓切除术，89例行肿瘤切除＋门静脉切开癌栓取出术；术后68例行经导管动脉内化疗栓塞术（TACE）治疗。36例肝细胞癌合并肝静脉癌栓患者均行肿瘤联合癌栓切除术，术后24例行TACE治疗。44例肝细胞癌合并胆管癌栓患者中，23例行肿瘤联合癌栓切除术，21例行肿瘤切除＋胆总管切开癌栓取出术；术后29例行TACE治疗。（3）随访和生存情况：①220例患者均获得随访，随访时间为1～73个月，中位随访时间为12个月。140例肝细胞癌合并门静脉癌栓患者中位生存时间为12个月，1、3、5年生存率分别为48.2%、25.0%、15.4%。36例肝细胞癌合并肝静脉癌栓患者中位生存时间为28个月，1、3、5年生存率分别为77.1%、45.6%、24.5%。44例肝细胞癌合并胆管癌栓患者中位生存时间为36个月，1、3、5年生存率分别为88.6%、48.3%、24.6%，3者生存情况比较，差异有统计学意义（x2=13.316，P〈0.05）。②140例肝细胞癌合并门静脉癌栓患者中，Ⅰ型癌栓49例，中位生存时间为20个月，1、3、5年生存率分别为60.3%、32.6%、17.1%；Ⅱ型癌栓70例，中位生存时间为13个月，1、3、5年生存率分别为51.4%、26.0%、17.3%；Ⅲ型癌栓21例，中位生存时间为7个月，1、3、5年生存率分别为9.5%、4.8%、0，3者生存情况比较，差异有统计学意义（x2=18.102，P〈0.05）。51例行肿瘤联合癌栓切除术患者中位生存时间为21个月，1、3、5年生存率分别为72.5%、42.5%、26.2%，89例行肿瘤切除＋门静脉切开癌栓取出术患者中位生存时间为9个月，1、3、5年生存率分别为40.0%、14.4%、0，两者生存情况比较，差异有统计学意义（x2=24.098，P〈0.05）。③36例肝细胞癌合并肝静脉癌栓患者中，肝右静脉癌栓17例，中位生存时间为14个月，1、3、5年生存率分别为64.7%、20.2%、0；肝左静脉癌栓10例，中位生存时间为53个月，1、3、5年生存率分别为80.0%、70.0%、38.9%；肝中静脉癌栓9例，中位生存时间为40个月，1、3、5年生存率分别为88.9%、61.0%、30.5%，3者生存情况比较，差异无统计学意义（x2=5.951，P〉0.05）。④44例肝细胞癌合并胆管癌栓患者中，Ⅰ型癌栓24例, 中位生存时间为38个月， 1、3、5年生存率分别为87.5%、60.4%、34.9%；Ⅱ型癌栓6例，中位生存时间为26个月，1、3、5年生存率分别为83.3%、16.7%、0；Ⅲ型癌栓14例，中位生存时间为35个月，1、3、5年生存率分别为78.6%、50.0%、21.4%，3者生存情况比较，差异无统计学意义（x2=5.312，P〉0.05）。44例患者中，23例行肿瘤联合癌栓切除术患者中位生存时间为38个月，1、3、5年生存率分别为91.3%、59.5%、34.3%；21例行肿瘤切除＋胆总管切开癌栓取出术患者中位生存时间为26个月，1、3、5年生存率分别为85.7%、35.7%、15.3%，两者生存情况比较，差异无统计学意义（x2=2.071，P〉0.05）。结论：肝细胞癌合并门静脉癌栓肿瘤直径更大，肝功能损害更重，更易出现腹腔积液。肝细胞癌合并不同脉管癌栓患者行手术治疗，合并胆管癌栓患者生存预后较好，合并肝静脉癌栓患者预后次之，合并门静脉癌栓患者预后较差。肝细胞癌合并门静脉癌栓术后生存与癌栓分型有关，分型越早，预后越好，行肿瘤联合癌栓切除术预后较好。肝细胞癌合并胆管癌栓术后生存与癌栓分型无关，行肿瘤联合癌栓切除术可能延长患者术后生存时间。

Objective：To compare the clinical features and surgical outcomes of hepatocellular carcinoma （HCC） combined with portal venous tumor thrombus （PVTT） and hepatic venous tumor thrombus （HVTT） or bile duct tumor thrombi （BDTT）, and analyze the effects of different tumor thrombus （TT） types and different surgical methods for TT on prognosis.Methods：The retrospective cross-sectional study was conducted. The clinical data of 220 HCC patients with lymphovascular invasion （LVI） who were admitted to the Affiliated Cancer Hospital of Guangxi Medical University between January 2004 and December 2014 were collected. Of 220 patients, 140 were combined with PVTT, 36 with HVTT and 44 with BDTT. According to patients′ conditions, they underwent tumor and TT resection, and tumor resection ＋ TT removal or single TT removal. Observation indicators： （1） comparisons of clinical features of HCC patients with PVTT or HVTT or BDTT; （2） surgical and postoperative situations; （3） follow-up and survival. Follow-up using outpatient examination and telephone interview was performed to detect postoperative survival up to December 2015. Measurement data with normal distribution were represented as ±s. Comparisons among 3 indicators were analyzed using the one-way ANOVA, and comparisons between 2 indicators were analyzed using the t test. Comparisons of count data were analyzed using the chi-square test. The survival curve and rate were respectively drawn and calculated by the Kaplan-Meier method, and the Log-rank test was used for survival analysis. Results：（1） Comparisons of clinical features of HCC patients with PVTT or HVTT or BDTT： number of patients with Child-pugh A, Child-pugh B and peritoneal effusion, tumor diameter and cases with tumor capsule were respectively detected in 133, 7, 23, （10±4）cm, 91 in HCC patients with PVTT and 35, 1, 4, （9±4）cm, 27 in HCC patients with HVTT and 35, 9, 16, （6±4）cm, 15 in HCC patients with BDTT, with statistically significant differences （x2=12.693, 10.408, F=11.300, x2=17.188, P〈0.05）. （2） Surgical and postoperative situations： of 140 HCC patients with PVTT, 51 underwent tumor and PVTT resection, 89 underwent tumor resection ＋ PVTT removal through incising portal vein; 68 received postoperative transcatheter arterial chemoembolization （TACE）. Thirty-six HCC patients with HVTT underwent tumor and HVTT resection; 24 received postoperative TACE. Of 44 HCC patients with BDTT, 23 underwent tumor and BDTT resection, 21 underwent tumor resection ＋ BDTT removal through incising common bile duct; 29 received postoperative TACE. （3） Follow-up and survival： ① 220 patients were followed up for 1-73 months, with a median time of 12 months. The median survival time, 1-, 3- and 5-year survival rates were respectively 12 months, 48.2%, 25.0%, 15.4% in 140 HCC patients with PVTT and 28 months, 77.1%, 45.6%, 24.5% in 36 HCC patients with HVTT and 36 months, 88.6%, 48.3%, 24.6% in 44 HCC patients with BDTT, with a statistically significant difference in survival （x2=13.316, P〈0.05）. ② Of 140 HCC patients with PVTT, 49 were in type Ⅰ PVTT, and median survival time, 1-, 3- and 5-year survival rates were respectively 20 months, 60.3%, 32.6% and 17.1%; 70 were in type Ⅱ PVTT, and median survival time, 1-, 3- and 5-year survival rates were respectively 13 months, 51.4%, 26.0% and 17.3%; 21 were in type Ⅲ PVTT, and median survival time, 1-, 3- and 5-year survival rates were respectively 7 months, 9.5%, 4.8% and 0, showing a statistically significant difference in survival （x2=18.102, P〈0.05）. The median survival time, 1-, 3- and 5-year survival rates were respectively 21 months, 72.5%, 42.5%, 26.2% in 51 patients undergoing tumor and TT resection and 9 months, 40%, 14.4%, 0 in 89 patients undergoing tumor resection ＋ PVTT removal through incising portal vein, showing a statistically significant difference in survival （x2=24.098, P〈0.05）. ③ Of 36 HCC patients with HVTT, 17 were detected in right HVTT, and median survival time, 1-, 3- and 5-year survival rates were respectively 14 months, 64.7%, 20.2% and 0; 10 were detected in left HVTT, and median survival time, 1-, 3- and 5-year survival rates were respectively 53 months, 80.0%, 70.0% and 38.9%; 9 were detected in middle HVTT, and median survival time, 1-, 3- and 5-year survival rates were respectively 40 months, 88.9%, 61.0% and 30.5%; showing no statistically significant difference in survival （x2=5.951, P〉0.05）. ④ Of 44 HCC patients with BDTT, 24, 6 and 14 were respectively detected in type Ⅰ, Ⅱ and Ⅲ BDTTs, and median survival time, 1-, 3- and 5-year survival rates were respectively 38 months, 87.5%, 60.4%, 34.9% in type Ⅰ BDTT patients and 26 months, 83.3%, 16.7%, 0 in type Ⅱ BDTT patients and 35 months, 78.6%, 50.0%, 21.4% in type Ⅲ BDTT patients, showing no statistically significant difference in survival （x2=5.312, P〉0.05）. Of 44 patients, median survival time, 1-, 3- and 5-year survival rates were respectively 38 months, 91.3%, 59.5%, 34.3% in 23 patients undergoing tumor and TT resection and 26 months, 85.7%, 35.7%, 15.3% in 21 patients undergoing tumor resection ＋ TT removal through incising common bile duct, showing no statistically significant difference in survival （x2=2.071, P〉0.05）. Conclusions：HCC patients with PVTT have larger tumor diameter and worse liver dysfunction, and are prone to peritoneal effusion. HCC patients with different LVI undergo surgery. There is better prognosis in HCC patients with BDTT, and good prognosis in patients with HVTT, while poorer prognosis in patients with PVTT. The postoperative survival of HCC patients with PVTT is associated with TT type, and patients will have better prognosis after tumor resection ＋ TT removal if TT type is confirmed earlier. The postoperative survival of HCC patients with BDTT is not associated with TT type, tumor resection ＋ TT removal maybe prolong postoperative survival time.