基于倾向性匹配对比外科手术与肝动脉化疗栓塞联合放疗治疗肝癌合并门静脉癌栓效果研究

Transarterial chemoembolization plus radiotherapy vs.surgery for hepatocellular carcinoma with portal vein tumor thrombosis

目的对比分析外科手术与肝动脉化疗栓塞(TACE)+放疗(RT)治疗肝细胞癌(HCC)合并门静脉癌栓(PVTT)的临床疗效。方法回顾性分析2000—2017年广西医科大学附属肿瘤医院收治的接受TACE+RT治疗的37例HCC+PVTT病人和2014—2017年接受外科手术的125例HCC合并PVTT病人的临床资料,倾向性评分配对后,共入组27对病人。采用Kaplan-Meier法计算生存并行log-rank检验。结果倾向性评分匹配前,外科手术组与TACE+RT组的生存时间相近(13.9个月vs.14.0个月,P=0.810);外科手术组1、2、3、5年总体生存率分别为52.8%、33.3%、27.9%和16.2%,而TACE+RT组为56.3%、33.4%、27.3%和17.7%。匹配后,外科手术组与TACE+RT组生存时间差异仍无统计学意义(10.0个月vs.13.0个月,P=0.520);外科手术组1、2、3、5年总体生存率为48.1%、33.3%、16.7%和11.1%,而TACE+RT组为51.6%、31.3%、22.3%和17.9%。按PVTT程氏分型(Ⅰ、Ⅱ、Ⅲ型)进行亚组分析,外科手术组和TACE+RT组的生存差异均无统计学意义(P<0.05);外科手术组中Ⅰ型PVTT的生存优于Ⅱ、Ⅲ型PVTT(19.1个月vs.11.8个月,P=0.028)。结论外科手术与TACE+RT治疗可切除的HCC合并PVTT病人的生存获益相近;手术切除可作为HCC合并Ⅰ型PVTT一线治疗方案,对于Ⅱ、Ⅲ型PVTT病人,TACE+RT可能是有效的一线治疗方案,但仍需进一步开展研究验证。

Objective To retrospectively compare the efficacy of transarterial chemoembolization(TACE)plus radiotherapy(RT)or surgery in the treatment of hepatocellular carcinoma(HCC)with portal vein tumor thrombosis(PVTT).Methods The clinical data of 37 patients with HCC+PVTT who received TACE+RT and 125 patients who received surgery in Guangxi Medical University Cancer Hospital from 2000 to 2017,were analyzed retrospectively.After matching,27 well-paired patients were selected.Survival was calculated using the Kaplan-Meier method with the logrank test.ResultsBefore propensity score matching,the median OS was comparable between the TACE+RT group and surgery group(14.0 months vs.13.9 months,P=0.810).The 1-,2-,3-,and 5-year accumulative OS were 56.3%,33.4%,27.3%,and 17.7% in the TACE+RT group,and 52.8%,33.3%,27.9%,and 16.2% in the surgery group,respectively.After matching(n=27),There was also no statistically significant difference in OS between the TACE+RTgroup and surgery group(median 13.0 vs.10.0 months,P=0.520).The 1-,2-,3-and 5-years OS were 51.6%,31.3%,22.3%and 17.9% in TACE+RT group,and 48.1%,33.3%,16.7% and 11.1% in the surgery group,respectively.There was no statistically significant difference in survival between the surgery group and the TACE+RT group among Cheng’s classification(type Ⅰ,Ⅱ,Ⅲ).However the Cheng’s classification of PVTT had a significant effect on postoperative survival,with the survival ofⅠtype better than that of Ⅱ/Ⅲ type(median 19.1 months vs.11.8 months,P=0.028).Conclusion The survival outcome is similar after receiving surgery and TACE+RT for patients with HCC+PVTT.Surgical resection is more effective for Cheng’s classification type Ⅰ than type Ⅱ/Ⅲ.TACE+RT may be an effective first-line treatment for Ⅱ/Ⅲ type of PVTT.Further multicenter prospective randomized controlled studies are still needed to verify the effect.