射频消融术治疗结直肠癌肝转移瘤的疗效及影响因素分析

Analysis of therapeutic effect and influencing factors of radiofrequency ablation for colorectal cancer liver metastases

目的探索射频消融术(RFA)治疗结直肠癌肝转移瘤(CRLM)的疗效和影响因素。方法回顾性分析浙江大学医学院附属邵逸夫医院2009年12月至2020年12月接受经皮RFA治疗的281例患者(477个肝内转移肿瘤灶)的临床及影像资料,并记录可能影响RFA疗效的因素,包括癌胚抗原(CEA)、分化、肝外转移情况、肿瘤位置和大小、并发症等信息。通过入院复查、电话等方式随访患者,主要终点为总生存期(OS)和局部肿瘤无进展生存期(LTPFS)。采用单因素和多因素logistic回归模型筛选肿瘤残余的预测因素。采用单因素和多因素Cox比例风险回归确定LTPFS和OS的影响因素。Kaplan-Meier曲线评估LTPFS和OS的中位时间,并使用对数秩检验进行比较。结果RFA后,观察到68个(14.3%)肿瘤残余。多因素logistic回归显示,肿瘤残余的危险因素为肿瘤直径≥20 mm、高危位置、血管周围位置和<5 mm的最小消融边缘。随访期间,主要并发症发生率为4.3%(12/281),病死率为31.3%(88/281),同时发现167个(35.0%)病灶术后局部肿瘤进展。Kaplan-Meier法估计的LTPFS和OS中位时间分别为35.0(95%CI 26.53~43.48)个月和44.0(95%CI 29.70~58.30)个月,第5年累计LTPFS和OS比例分别为37.2%和40.4%。多因素Cox比例风险回归显示,CEA≥30 ng/ml、肿瘤直径≥20 mm和最小消融边缘<5 mm为LTPFS的危险因素;肝外转移、肿瘤负荷>30 mm和含最小消融边缘<5 mm的肿瘤是OS的独立危险因素,再次介入治疗是OS的独立保护因素。结论足够的消融边缘和较少的肿瘤负荷有利于RFA后局部肿瘤的控制和患者长期生存;存在肝外转移是OS的重要危险因素,而再次介入治疗有利于提高OS。

Objective To explore the efficacy and influencing factors of radiofrequency ablation(RFA)in the treatment of colorectal cancer liver metastases(CRLM).Methods The clinical and imaging data of 281 patients(477 intrahepatic metastatic tumors)who received percutaneous RFA treatment in Sir Run Run Shaw Hospital,Zhejiang University School of Medicine from December 2009 to December 2020 were retrospectively analyzed.Factors that may affect the efficacy of RFA were recorded,including carcinoembryonic antigen(CEA),differentiation,extrahepatic metastasis,tumor location and size,complications and other information.Patients were followed up through hospital admissions,telephone,etc.The primary endpoints were overall survival(OS)and local tumor progression-free survival(LTPFS).Univariate and multivariate logistic regression models were used to identify predictors of residual tumor.Univariate and multivariate Cox proportional hazards regression were used to identify the influencing factors of LTPFS and OS.The median LTPFS and OS were estimated by the Kaplan-Meier curve and compared by the log-rank test.Results After RFA,68(14.3%)tumor residues were observed.Multivariate logistic regression showed that the risk factors for residual tumor were size≥20 mm,high-risk and perivascular location,and minimal ablative margin<5 mm.During the follow-up period,the main complication rate was 4.3%(12/281)and the fatality rate was 31.3%(88/281).At the same time,local tumor progression was found in 167(35.0%)lesions post-RFA.The median time of LTPFS and OS estimated by the Kaplan Meier method were 35.0(95%CI 26.53-43.48)and 44.0(95%CI 29.70-58.30)months,respectively.The cumulative proportion of LTPFS and OS were 37.2%and 40.4%respectively in the 5th year.Multivariate Cox proportional hazard regression showed that CEA≥30 ng/ml,tumor size≥20 mm,and minimal ablative margin<5 mm were risk factors for LTPFS;extrahepatic metastasis,tumor burden>30 mm,and lesion with minimal ablative margin<5 mm were independent risk factors for OS;re-intervention was an independent protective factor for OS.Conclusions Adequate ablative margin and less tumor burden were beneficial to local tumor control and long-term survival of patients in the RFA treatment;the existence of extrahepatic metastasis was an important risk factor for OS,and re-interventional therapy was beneficial to extend OS.