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中华介入放射学电子杂志 ›› 2016, Vol. 04 ›› Issue (02) : 71 -76. doi: 10.3877/cma.j.issn.2095-5782.2016.02.004

所属专题： 文献；

非血管介入

PVA-TACE治疗肝细胞癌并肝肺分流的临床疗效及预后分析
刘秋松1, 张恭良2, 梅雀林3, 李彦豪3,†()   
  1. 1. 361004　福建厦门，厦门大学附属中山医院肿瘤与血管介入科
    2. 510515　广东广州，南方医科大学南方医院放射科
    3. 510515　广东广州，南方医科大学南方医院介入科
  • 收稿日期:2016-03-10 出版日期:2016-05-01
  • 通信作者: 李彦豪

Polyvinyl alcohol chemoembolization for hepatocellular carcinoma with hepatopulmonary shunting: clinical efficacy and prognostic factors

Qiusong Liu1, Gongliang Zhang2, Quelin Mei3, Yanhao Li3,†()   

  1. 1. Department of Interventional Radiology, Affiliated Zhongshan Hospital, Xiamen University, Xiamen 361004, China
    2. Department of Radiology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
    3. Department of Interventional Radiology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
  • Received:2016-03-10 Published:2016-05-01
  • Corresponding author: Yanhao Li
  • About author:
    Corresponding author: Li Yanhao, Email:
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刘秋松, 张恭良, 梅雀林, 李彦豪. PVA-TACE治疗肝细胞癌并肝肺分流的临床疗效及预后分析[J]. 中华介入放射学电子杂志, 2016, 04(02): 71-76.

Qiusong Liu, Gongliang Zhang, Quelin Mei, Yanhao Li. Polyvinyl alcohol chemoembolization for hepatocellular carcinoma with hepatopulmonary shunting: clinical efficacy and prognostic factors[J]. Chinese Journal of Interventional Radiology(Electronic Edition), 2016, 04(02): 71-76.

目的：

评价聚乙烯醇微粒肝动脉化疗栓塞（PVA-TACE）治疗肝细胞癌（HCC）并肝肺分流（HPS）的临床疗效，分析影响生存预后的因素。

方法：

回顾性分析42例HCC并HPS患者资料，依据分流途径分为门静脉-腔静脉分流组（A组，9例）与肝动脉-肝静脉分流组（B组，33例）。依据分流速度采用不同规格聚乙烯醇（PVA）微粒进行肝动脉化疗栓塞（TACE）治疗，随访并分析生存期及术后并发症。采用Kaplan-Meier法计算累积生存率，采用Cox模型分析生存预后的影响因素。

结果：

42例患者中位生存期（OS）为9.5个月，6、12个月生存率分别为74.9%、39.4%。A组与B组中位OS分别为10.5个月、9.5个月，两组生存期无明显差异（χ2=0.410，P=0.522）。Cox回归分析结果显示：行为状态（PS）评分较高（HR=2.454，P=0.026）、肿瘤负荷>50%（HR=3.477，P=0.019）及门静脉主干癌栓形成（P=0.006）为预后的独立危险因素，而多次栓塞（HR=0.329，P=0.008）为预后的独立保护因素。

结论：

经谨慎选择病例，PVA-TACE治疗HCC合并HPS安全、有效。经多次栓塞治疗患者预后较好，而PS评分较高、肿瘤负荷较大及门静脉主干癌栓形成的患者预后不良。

关键词: 聚乙烯醇, 癌，肝细胞, 肝肺分流, 疗效, 预后分析
Objective:

To evaluate the efficacy and prognosis of polyvinyl alcohol (PVA) chemoembolization in treating hepatocellular carcinoma (HCC) with hepatopulmonary shunting (HPS).

Methods:

A total of 42 patients' clinical data were retrospectively analyzed. According to the shunting pathway, the patients were divided into group A (portal-systemic shunting, n=9) and group B (arterio-hepatic vein shunting, n=33). Based on shunting speed, different amount of PVA was used to embolize the shunts. The overall survival (OS) and postoperative complications, etc. were analyzed in the follow-up study. Survival prognostic factors were assessed by univariate Kaplan-Meier analysis with Log-rank test and a multivariate Cox proportional hazard model.

Results:

The median OS of the 42 patients was 9.5 months, and the 6-month, 12-month survival rate were 74.9% and 39.4%, respectively. The median OS of the group A and group B were 10.5 months and 9.5 months, respectively, showing no significant difference between two groups (χ2=0.410, P=0.522). Cox multivariate survival analysis revealed that higher performance status (PS) score (HR=2.454, P=0.026), tumor burden >50% (HR=3.477, P=0.019) and main portal vein invasion (P=0.006) were independent risk factors. Multiple embolization (HR=0.329, P=0.008) was an independent protection factor.

Conclusion:

PVA chemoembolization is a safe and effective strategy for selected HCC patients with HPS . Multiple embolization can achieve better survival prognosis in HCC with HPS patients while for those with, tumor burden >50% and main portal vein invasion it showed poor survival prognosis.

Key words: Polyvinyl alcohol, Carcinoma, hepatocellular, Hepatopulmonary shunting, Treatment outcome, Prognosis
表1 42例肝细胞癌合并肝肺分流患者的基线情况
参数 门静脉-腔静脉分流组（9例） 肝动脉-肝静脉分流组（33例） χ2值 P值
分流速度类型 ? ? ? ?
? 快速型 9 8 13.526 <0.001
? 中速型 0 11 ? ?
? 慢速型 0 14 ? ?
肿瘤边界 ? ? ? ?
? 局限型 4 29 7.735 0.005
? 浸润型 5 4 ? ?
肿瘤负荷 ? ? ? ?
? ≤50% 7 18 1.546 0.214
? >50% 2 15 ? ?
BCLC分期a ? ? ? ?
? B 2 7 0.004 0.948
? C 7 26 ? ?
AFP (μg/L) ? ? ? ?
? <400 3 15 0.414 0.520
? ≥400 6 18 ? ?
门静脉癌栓 ? ? ? ?
? 主干 5 5 1.423 0.233
? 一级分支 0 12 ? ?
? 无 4 16 ? ?
肝静脉癌栓 ? ? ? ?
? 有 0 13 5.013 0.025
? 无 9 20 ? ?
图1 巨块型肝癌并下腔静脉癌栓形成、中速型肝动脉-肝静脉分流，因急性肺动脉栓塞急诊入院。急诊行下腔静脉支架及肺动脉支架置入术，后续行多次PVA-TACE治疗。
图2 团块型肝癌并肝静脉-下腔静脉分流、右心房癌栓形成
图3 肝动脉-门静脉分流与肝动脉-肝静脉分流
表2 Cox回归分析肝细胞癌合并肝肺分流患者预后的影响因素
因素 β SE Waldχ2 df P HR（95%CI）
肿瘤负荷 1.246 0.530 5.529 1 0.019 3.477（1.231～9.826）
PS评分a 0.898 0.404 4.942 1 0.026 2.454（1.112～5.416）
多次栓塞治疗 -1.112 0.421 6.968 1 0.008 0.329（0.144～0.751）
门静脉癌栓 ? ? 10.166 2 0.006 ?
无:主干 -1.605 0.599 7.190 1 0.007 0.201（0.062～0.649）
一级分支:主干 -1.459 0.534 7.457 1 0.006 0.232（0.082～0.662）
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