初始不可切除肝癌行介入联合靶免转化治疗后序贯手术的疗效分析

Efficacy of sequential surgical resection for initial unresectable hepatocellular carcinoma after interventional therapy plus targeted immunotherapy

目的评估初始不可切除的晚期肝癌行局部介入治疗联合系统靶免转化治疗后序贯手术切除的临床疗效,分析其安全性、可行性。方法回顾性收集并分析西安交通大学医学院附属三二〇一医院自2021年6月至2023年4月期间收治的10例初始不可切除的晚期肝癌病人的临床资料。结果10例病人中,男性8例,女性2例,中位年龄55岁(33~72岁);Child-Pugh分级标准A级6例,B级4例;中国肝癌分期Ⅱb期4例,Ⅲa期6例;转化治疗前肿瘤最大径为13 cm,甲胎蛋白>400μg/L者7例,甲胎蛋白<400μg/L者3例;合并门静脉癌栓者6例,无门静脉癌栓者4例;转化治疗方案:肝动脉灌注化疗栓塞+靶免治疗的有6例、肝动脉灌注化疗+靶免的有4例,转化治疗过程中合并高血压4例、乏力2例、腹泻1例;中位转化时间为4个月;转化结束后术前的中位甲胎蛋白水平为7.2μg/L,肿瘤最大径缩小至8.8 cm,影像学评估完全缓解4例,部分缓解3例,疾病稳定3例;转化后行手术切除:3例行肝脏部分切除(2例右后叶切除,1例VI段切除),7例行半肝切除(2例左半肝切除,5例右半肝切除);经腹腔镜手术7例,开腹手术3例。中位手术时间为40 min,中位出血量为400 mL,术后中位住院时间为8 d,中位拔除腹腔引流管时间为7 d。术后病理提示病理学完全缓解3例,病理学部分缓解有7例,微血管侵犯分级M0(无微血管侵犯)有8例,M1(≤5个微血管侵犯)有2例,术后切缘均为阴性。术后中位随访时间为8个月,1例复发,无病例死亡。结论部分初始不可切除的晚期肝癌病人,行介入联合靶免转化治疗后序贯手术切除,疗效确切,安全性可。

Objective To evaluate the clinical efficacy of sequential surgical resection for initial unresectable hepatocellular carcinoma(HCC)after interventional therapy plus targeted immunotherapy.Methods From June 2021 to April 2023,retrospective review was performed for the relevant clinical data from 10 patients of initial unresectable HCC.Results There were 8 males and 2 females with a median age of 55(33-72)years.Child Pugh grade was A(n=6)and B(n=4).And China Liver Cancer(CNLC)stage wasⅡb(n=4)andⅢa(n=6).Portal vein cancer thrombus was present(n=6)or absent(n=4).Maximal tumor diameter prior to transformation therapy was 13 cm.The pre-treatment level of alpha feto-protein(AFP)was>400μg/L(n=7)and<400μg/L(n=3).Conversion treatment protocol was transcatheter arterial chemoembolization(TACE)plus targeted immunotherapy(n=6)and hepatic artery infusion chemotherapy(HAIC)plus targeted immunotherapy(n=4).There were hypertension(n=4),fatigue(n=2)and diarrhea(n=1)during treatment.Median conversion time was 4 months.Median preoperative level of AFP after conversion therapy was 7.2μg/L and maximal preoperative diameter of tumor after conversion therapy 8.8 cm.Preoperative imaging assessment of outcomes was complete remission(CR,n=4),partial remission(PR,n=3)and stable disease(SD,n=3).After therapy,the procedures included partial hepatectomy(n=3),semi-hepatic resection(n=7),laparoscopy(n=7)and open surgery(n=3).Median surgical time was 240 min,median intraoperative volume of blood loss 400 mL,median postoperative hospital stay 8 days and median postoperative drainage tube removal time 7 days.Postoperative pathological results were pCR(n=3)and pPR(n=7).MVI grade was M0(n=8)and M1(n=2).There was no positive case of resection margin.There were postoperative ascites(n=1)and bile leakage(n=1).No obvious postoperative complications occurred.During a median postoperative follow-up period of 8 months,one case recurred and there was no death.Conclusion For initial unresectable HCC,sequential surgical resection along with interventional therapy plus targeted immunotherapy is both effective and safe.