PVA-TACE治疗肝癌并肝动-静脉分流的疗效及生存预后

Evaluation of polyvinyl alcohol transcatheter arterial chemoembolization in treating hepatocellular carcinoma with hepatic arteriovenous shunts and its prognosis

目的：探讨聚乙烯醇微粒肝动脉化疗栓塞（PVA-TACE）治疗肝细胞癌（HCC）并肝动-静脉分流（HAVS）的疗效预测及生存预后影响因素分析。方法：回顾性分析113例HCC并HAVS，依据分流速度不同采用不同规格PVA化疗栓塞。依据疗效分为肿瘤控制组（A组，63例）与肿瘤进展组（B组，50例），随访并分析生存期，采用Kaplan-Meier法计算累积生存率，疗效预测因素采用多因素logistic回归分析，生存预后因素采用Cox模型分析。结果：113例患者的中位生存期（OS）为11.0个月。A、B组中位OS分别为14.5个月、9.2个月，两组患者的生存期差异有统计学意义（χ2=15.215，P<0.001）。多因素logistic回归分析显示：肿瘤分布于单叶（OR=0.222，P=0.003）及无癌栓形成（OR=0.126，P=0.024）患者的疗效较好。多因素Cox回归分析显示：年龄≤50岁（HR=0.616，P=0.049）、多次栓塞治疗（HR=0.550，P=0.039）及肿瘤控制（HR=0.443，P=0.002）为预后的独立保护因素，而肿瘤负荷>50%（HR=3.156，P<0.001）及分流栓塞程度较低（HR=2.011，P=0.002）为预后的独立危险因素。结论：PVA-TACE治疗HCC并HAVS是安全、有效的。肿瘤单叶分布及无血管癌栓侵犯肿瘤控制较好。肿瘤负荷较大及分流栓塞程度较低患者预后较差，年轻、多次栓塞治疗及肿瘤控制的患者预后较好。

Objective: To evaluate the efficacy of polyvinyl alcohol transcatheter arterial chemoembolization (PVA-TACE) in the treatment of hepatocellular carcinoma (HCC) with hepatic arteriovenous shunts (HAVS) and its prognosis among these patients. Methods: 113 patients with HCC and HAVS were collected who were divided into two groups according to their responding to the therapeutics-group A (tumor control, n=63)and group B (tumor progress, n=50). Based on HAVS types, different sizes of PVA were used to embolize the shunts accordingly. The overall survival (OS) was analyzed in the follow-up study. Factors associated with efficacy wereevaluated using multivariate logistic regression analysis. The survival prognostic factors were assessed by multivariateCox analysis. Results: The median OS of 113 patients was 11.0 months. The median OS of the group A and group Bpatients were 14.5 months and 9.2 months, respectively. The survival curves of the two groups were estimated by theKaplan–Meier method and compared by a Log-rank test, which revealed a significant difference between two groups(χ2=15.215, P<0.001). On multivariate logistic analysis, tumor location (OR=0.222, P=0.003) and tumor thrombosis(OR=0.126, P=0.024) were significant factors for efficacy. Independent prognostic factors for a longer survivalincluded: patient age ≤50 years (HR=0.616, P=0.049), multiple embolization (HR=0.550, P=0.039) and tumor control(HR=0.443, P=0.002). While tumor burden >50% (HR=3.156, P<0.001) and lower level of shunts occlusion wereconsidered independent risk factors. Conclusions: PVA-TACE is a safe and effective strategy for HCC with HAVS ,especially for single-lobe tumor and without tumor thrombosis. Younger age, multiple embolization and tumor control show a better survival prognosis. Patients with tumor burden>50% and lower level of shunts occlusion show a poor survival prognosis.