声辐射力弹性成像对不可切除肝细胞癌门静脉癌栓患者放射治疗效果的评价

Acoustic radiation force imaging for evaluating efficacy of radiotherapy in unresectable hepatocellular carcinoma patients with portal vein tumor thrombus

目的探讨声辐射力弹性成像(ARFI)声触诊组织定量(VTQ)技术在不可切除肝细胞癌(HCC)伴门静脉癌栓(PVTT)放射治疗疗效评估中的价值。方法回顾性分析2016年1月至2023年12月东部战区总医院、南京医科大学第一附属医院以及南京江北医院行放射治疗的不可切除HCC伴PVTT患者共73例。所有患者放射治疗前一周、结束后一个月均行常规超声、ARFI及增强CT检查。以PVTT分型降型率将患者分为降型组和非降型组。使用单因素和多因素Logistic回归模型分析两组患者临床病理、ARFI特征与降型率的相关性。依据多因素Logistic回归结果,将具有统计学意义的参数纳入多因素Cox回归生存分析模型,得到与患者生存预后独立相关的因素。结果放射治疗后PVTT降型率为35.62%(26/73),升型率为4.11%(3/73),稳定率为60.27%(44/73)。单因素分析结果显示放射治疗前后甲胎蛋白(APF)水平、肝硬化程度、HCC分化程度、放射治疗前后剪切波速度(SWV)以及SWV变化率在降型组与非降型组间差异具有统计学意义(P<0.05)。多因素Logistic回归分析结果显示,肝硬化程度(重度OR值:9.671,95%CI:1.420~65.887,P=0.020)、HCC分化程度(中分化OR值:0.158,95%CI:0.026~0.950,P=0.044;低/未分化OR值:3.216,95%CI:0.541~19.115,P=0.045)、放射治疗后AFP水平>14 ng/ml(OR值:11.890,95%CI:2.274~62.169,P=0.003)以及SWV变化率≤20%(OR值:15.675,95%CI:2.008~122.353,P=0.009)均与患者是否降型独立相关。多因素Cox回归生存分析模型结果显示,放射治疗后AFP水平>14 ng/ml(OR值:2.133,95%CI:1.188~3.830,P=0.011)、HCC分化程度(低/未分化OR值:4.041,95%CI:1.823~8.959,P=0.001)以及SWV变化率≤20%(OR值:2.649,95%CI:1.450~4.842,P=0.002)均与患者生存预后独立相关。结论放射治疗后APF水平、HCC分化程度以及SWV变化率与不可切除HCC伴PVTT患者放射治疗后是否降型及生存率显著相关,是评价其疗效的重要指标。VTQ是评价HCC合并PVTT放射治疗疗效的有效手段,可为临床决策提供影像学依据。

Objective To assess the clinical value of acoustic radiation force imaging(ARFI)with virtual touch quantification(VTQ)technique in evaluating the efficacy of radiation therapy for unresectable hepatocellular carcinoma(HCC)patients with portal vein tumor thrombus(PVTT).Methods A total of 73 patients with unresectable HCC with PVTT who received radiotherapy at the Eastern Theater Command General Hospital,the First Affiliated Hospital of Nanjing Medical University,and Nanjing Jiangbei Hospital from January 2016 to December 2023 were retrospectively analyzed.All patients underwent routine ultrasound,ARFI,and enhanced CT examination one week before and one month after radiotherapy.The patients were divided into a downstaging group and non-downstaging group according to the PVTT downstaging rate.Univariate and multivariate Logistic regression models were used to analyze the correlation of clinicopathologic parameters and,ARFI characteristics with the downstaging rate of the two groups of patients.According to the results of multivariate Logistic regression,statistically significant parameters were incorporated into the multivariate Cox survival analysis model,and factors independently related to the survival outcome of patients were identified.Results After radiotherapy,the downstaging rate of PVTT was 35.62%(26/73),the upstaging rate was 4.11%(3/73),and the stable rate was 60.27%(44/73).Univariate analysis showed that there were significant differences in alpha-fetal protein(APF)level before and after radiotherapy,cirrhosis degree,HCC differentiation degree,shear wave velocity(SWV)before and after radiotherapy,and SWV change rate between the downstaging group and non-downstaging group(P<0.05).Multivariate Logistic regression analysis showed the degree of cirrhosis(severe:odds ratio[OR]=9.671,95%confidence interval[CI]:1.420-65.887,P=0.020),the differentiation degree of HCC(intermediate:OR=0.158,95%CI:0.026-0.950,P=0.044;low/undifferentiation:OR=3.216,95%CI:0.541-19.115,P=0.045),AFP level>14 ng/ml after radiotherapy(OR=11.890,95%CI:2.274-62.169,P=0.003),and SWV change rate≤20%(OR=15.675,95%CI:2.008-122.353,P=0.009)were independently correlated with the patients'downstaging rate.Multivariate Cox survival analysis showed that AFP level>14 ng/ml(OR=2.133,95%CI:1.188-3.830,P=0.011),HCC differentiation degree(low/undifferentiation:OR=4.041,95%CI:1.823-8.959,P=0.001),and SWV change rate≤20%(OR=2.649,95%CI:1.450-4.842,P=0.002)were independently associated with survival outcome.Conclusion The level of APF after radiotherapy,the degree of differentiation of HCC,and the change rate of SWV are significantly correlated to whether PVTT has been downstaged or not and correlated with the survival outcome of unresectable HCC patients with PVTT,which are important indicators to evaluate the efficacy of radiotherapy.VTQ is an effective method to evaluate the efficacy of radiotherapy for HCC combined with PVTT,and can provide imaging evidence for clinical decision-making.