PVE或PVE联合TACE对肝细胞癌二期手术及预后的影响

Influence of PVE and PVE combined with TACE on secondary hepatectomy and prognosis of hepatocellular carcinoma

目的探讨门静脉栓塞术(PVE)或PVE+经导管动脉化疗栓塞术(TACE)对无法一期切除肝细胞癌患者行二期手术及预后的影响。方法采用回顾性队列研究方法。收集2015年10月26日至2022年12月31日海军军医大学第三附属医院收治102例无法一期切除的肝细胞癌患者的临床资料;男82例,女20例;年龄为52(25~73)岁。102例患者中,72例患者转化治疗方法采用PVE+TACE,设为PVE+TACE组;30例采用PVE,设为PVE组。观察指标:(1)二期手术切除率和剩余肝体积(FLR)增长情况。(2)二期手术治疗情况。(3)随访情况。正态分布的计量资料以x±s表示,组间比较采用独立样本t检验。偏态分布的计量资料以M(范围)表示,组间比较采用Mann-WhitneyU检验。计数资料以绝对数表示,组间比较采用χ^(2)检验或Fisher确切概率法。等级资料组间比较采用Mann-WhitneyU检验。Kaplan-Meier法计算生存率并绘制生存曲线,采用Log-Rank检验进行生存分析。结果(1)二期手术切除率和FLR增长情况。PVE+TACE组、PVE组患者二期手术切除率分别为72.2%(52/72)、53.3%(16/30),两组比较,差异无统计学意义(χ^(2)=3.400,P>0.05)。PVE+TACE组52例行二期手术患者二期手术等待时间、FLR增长量、FLR增长速度分别为20(14~140)d、140(62~424)mL、9.8(1.5~26.5)mL/d;PVE组16例行二期手术患者上述指标分别为16(12~35)d、160(95~408)mL、10.5(1.2~28.0)mL/d;两组患者上述指标比较,差异均无统计学意义(Z=1.830,1.498,1.266,P>0.05)。(2)二期手术治疗情况。PVE+TACE组52例行二期手术患者手术时间,肿瘤坏死率(>90%、60%~90%、<60%),≥Ⅲa级并发症情况分别为200(125~420)min,8、4、40例,28例;PVE组16例行二期手术患者上述指标分别为170(105~320)min,0、0、16例,4例;两组患者上述指标比较,差异均有统计学意义(Z=2.132、-2.093,χ^(2)=4.087,P<0.05)。(3)随访情况。68例完成手术患者均获得随访,随访时间为40(10~84)个月。PVE+TACE组52例行二期手术患者1、3、5年无复发生存率分别为73.0%、53.3%、35.4%,PVE组16例行二期手术患者的1、3、5年无复发生存率分别为62.5%、37.5%、18.8%,两组患者无复发生存率比较,差异有统计学意义(χ^(2)=4.035,P<0.05)。PVE+TACE组52例行二期手术患者1、3、5年总生存率分别为82.5%、61.2%、36.6%,PVE组16例行二期手术患者的1、3、5年总生存率分别为68.8%、41.7%、20.8%,两组患者总生存率比较,差异有统计学意义(χ^(2)=4.767,P<0.05)。结论PVE+TACE治疗作为一期手术可以提高二期手术切除率和患者无复发生存率,远期生存也优于一期手术单行PVE治疗患者,并且不会影响患者FLR增长速度。

Objective To investigate the influencing of portal vein embolization(PVE)and PVE combined with transcatheter arterial chemoembolization(TACE)on secondary hepatectomy and prognosis of patients with initially unresectable hepatocellular carcinoma(HCC).Methods The retrospective cohort study was conducted.The clinicopathological data of 102 patients with initially unresectable HCC who were admitted to the Third Affiliated Hospital of Naval Medical University from October 26,2015 to December 31,2022 were collected.There were 82 males and 20 females,aged 52(range,25‒73)years.Of 102 patients,72 cases undergoing PVE combined with TACE were set as the PVE+TACE group,and 30 cases undergoing PVE were set as the PVE group.Observation indicators:(1)surgical resection rate of secondary hepatectomy and increase of future liver remnant(FLR);(2)situations of secondary hepatectomy;(3)follow‐up.Measurement data with normal distribution were represented as Mean±SD,and comparison between groups was conducted using the independent sample t test.Measurement data with skewed distribution were represented as M(range),and comparison between groups was conducted using the Mann‐Whitney U test.Count data were described as absolute numbers,and comparison between groups was conducted using the chi‐square test or Fisher exact probability.Comparison of ordinal data was conducted using the Mann-Whitney U test.The Kaplan‐Meier method was used to calculate survival rate and draw survival curve,and Log‐Rank test was used for survival analysis.Results(1)Surgical resection rate of secondary hepatectomy and increase of FLR.The surgical resection rate of secondary hepatectomy in the PVE+TACE group and the PVE group were 72.2%(52/72)and 53.3%(16/30),respectively,showing no significant difference between the two groups(χ2=3.400,P>0.05).The surgical waiting time,increasing volume of FLR,growth rate of FLR in the 52 patients of PVE+TACE group receiving secondary hepatectomy were 20(range,14‒140)days,140(range,62‒424)mL,9.8(range,1.5‒26.5)mL/day,respectively.The above indicators in the 16 patients of PVE group receiving secondary hepatectomy were 16(range,12‒35)days,160(range,95‒408)mL,10.5(range,1.2‒28.0)mL/day,respectively.There was no significant difference in the above indicators between the 52 patients of PVE+TACE group and the 16 patients of PVE group(Z=1.830,1.498,1.266,P>0.05).(2)Situations of secondary hepatectomy.The operation time,rate of tumor necrosis(>90%,60%‒90%,<60%),cases with complications≥gradeⅢa in the 52 patients of PVE+TACE group receiving secondary hepatectomy were 200(range,125‒420)minutes,8,4,40,28,respectively.The above indicators in the 16 patients of PVE group receiving secondary hepatectomy were 170(range,105‒320)minutes,0,0,16,4,respectively.There were significant differences in the above indicators between the 52 patients of PVE+TACE group and the 16 patients of PVE group(Z=2.132,‒2.093,χ^(2)=4.087,P<0.05).(3)Followup.Sixty‐eight patients who completed the surgery were followed up for 40(range,10‒84)months.The 1‐,3‐,5‐year recurrence free survival rate in the 52 patients of PVE+TACE group receiving secondary hepatectomy were 73.0%,53.3%,35.4%,respectively.The above indicators in the 16 patients of PVE group were 62.5%,37.5%,18.8%,respectively.There was a significant difference in the recurrence free survival rate between the 52 patients of PVE+TACE group and the 16 patients of PVE group(χ^(2)=4.035,P<0.05).The 1‐,3‐,5‐year overall survival rate in the 52 patients of PVE+TACE group receiving secondary hepatectomy were 82.5%,61.2%,36.6%,respectively.The above indicators in the 16 patients of PVE group receiving secondary hepatectomy were 68.8%,41.7%,20.8%,respectively.There was a significant difference in the overall survival rate between the 52 patients of PVE+TACE group and the 16 patients of PVE group(χ^(2)=4.767,P<0.05).Conclusion Compared with PVE,PVE+TACE as stageⅠsurgery can increase the surgical resection rate of secondary hepatectomy and the recurrence free survival rate of patients with initially unresectable HCC,prolong the long‐term survival time,but not influence the growth rate of FLR.