靶向免疫治疗对晚期肝癌食管胃静脉曲张破裂出血患者内镜治疗后再出血的影响

The effect of targeted immunotherapy on re bleeding after endoscopic treatment in patients with advanced liver cancer and esophageal and gastric variceal bleeding

目的探讨既往靶向免疫治疗停用后是否增加晚期肝癌合并食管胃静脉曲张破裂出血患者内镜治疗后的再出血风险。方法采取回顾性队列研究,纳入2020年3月1日至2022年3月1日因上消化道出血就诊于复旦大学附属中山医院的晚期肝癌患者,均经内镜检查诊断为食管胃静脉曲张破裂出血,并行内镜下治疗。收集患者临床资料,根据出血前是否接受靶向免疫治疗,分为靶免组和非靶免组;随访观察6个月,评价患者再出血和生存情况。结果共纳入55例患者,其中24例既往接受靶向免疫治疗,31例未接受过靶向免疫治疗。两组患者在性别分布、病因、合并高血压、糖尿病等方面的差异无统计学意义(均P>0.05)。靶免组年龄小于非靶免组,纤维蛋白原水平高于非靶免组,差异均有统计学意义(P=0.002、0.017)。靶免组和非靶免组患者的6个月再出血率(20.83%vs 22.58%,P=0.269)、6个月病死率(45.83%vs 29.03%,P=0.199)差异无统计学意义。进一步的Cox回归多因素分析发现,Child-pugh分级是影响晚期肝癌食管胃静脉曲张患者6个月生存的独立危险因素(HR=2.64,P=0.009)。结论靶向免疫治疗停药后不增加晚期不可切除肝癌患者食管胃静脉曲张内镜治疗后的再出血率。Child-pugh分级是晚期肝癌患者出血后6个月生存的影响因素,且肝功能越差,生存期越短。

Objective To investigate whether discontinuation of previous targeted immunotherapy increases the risk of rebleeding in patients with advanced liver cancer complicated with esophageal and gastric variceal bleeding after endoscopic treatment.Methods A retrospective cohort study was conducted to include advanced liver cancer patients who were diagnosed with esophageal and gastric variceal bleeding through endoscopic examination and treated under endoscopy at Zhongshan Hospital,Fudan University from March 1,2020 to March 1,2022,due to upper gastrointestinal bleeding.We collected clinical data from patients and divided them into targeted immunotherapy group and non targeted immunotherapy group based on whether they received targeted immunotherapy before bleeding;Follow up observation was conducted for 6 months to evaluate the patient's re bleeding and survival status.Results A total of 55 patients were included,of which 24 had previously received targeted immunotherapy and 31 had not received targeted immunotherapy.There was no significant difference between the two groups in gender distribution,etiology,hypertension and diabetes(all P>0.05).The age of the target immunotherapy group was younger than that of the non target immunotherapy group,and the level of fibrinogen was higher than that of the non target immunotherapy group,with statistical significance(P=0.002,0.017).There was no statistically significant difference in the 6-month re bleeding rate(20.83%vs 22.58%,P=0.269)and 6-month mortality rate(45.83%vs 29.03%,P=0.199)between the targeted and non targeted groups of patients.Further Cox regression multivariate analysis revealed that Child-pugh grading was an independent risk factor for 6-month survival in patients with advanced liver cancer with esophageal and gastric varices(HR=2.64,P=0.009).Conclusions Targeted immunotherapy does not increase the rate of rebleeding in patients with advanced unresectable liver cancer after endoscopic treatment of esophageal and gastric varices.Child-pugh grading is a factor that affects the 6-month survival of advanced liver cancer patients after bleeding,and the poorer the liver function,the shorter the survival period.