司增梅　錢　晟　劉　嶸　瞿旭東　龔高全　王小林　顏志平　王建華 △

(1上海市影像醫(yī)學(xué)研究所　上?！?00032; 2 復(fù)旦大學(xué)附屬中山醫(yī)院介入科　上海　200032)

?

微波消融同步聯(lián)合TACE治療大肝癌和巨塊型肝癌的臨床療效分析

司增梅1,2錢晟1,2劉嶸1,2瞿旭東1,2龔高全1,2王小林1,2顏志平1,2王建華1,2 △

(1上海市影像醫(yī)學(xué)研究所上海200032;2復(fù)旦大學(xué)附屬中山醫(yī)院介入科上海200032)

目的評(píng)價(jià)微波消融(microwave ablation,MWA)同步聯(lián)合經(jīng)動(dòng)脈化療栓塞(transarterial chemoembolization,TACE)治療大肝癌(直徑>5 cm)和巨塊型肝癌(直徑>10 cm)的安全性和有效性。方法回顧性分析2013年3月至2014年12月期間在復(fù)旦大學(xué)附屬中山醫(yī)院行經(jīng)皮MWA同步聯(lián)合TACE治療的65例大肝癌或巨塊型肝癌患者(腫瘤直徑5～18 cm),治療程序?yàn)橄刃袆?dòng)脈數(shù)字減影血管造影(digital subtraction angiography,DSA),接著超聲引導(dǎo)下行經(jīng)皮MWA,最后行再次血管造影并選擇TACE治療。結(jié)果同步治療耐受性好。造影劑外滲3例,經(jīng)栓塞后消失。術(shù)后僅見(jiàn)輕微肝功能受損和血液毒性及少量的胸腔積液,未見(jiàn)膿腫、膽道損傷、肝功能衰竭及其他手術(shù)相關(guān)的嚴(yán)重并發(fā)癥。TACE碘油栓塞劑用量平均為8 mL。隨訪2～21個(gè)月,65例患者無(wú)疾病進(jìn)展生存時(shí)間為(6.3±1.5)個(gè)月,中位生存時(shí)間為14個(gè)月,6、12及18個(gè)月的生存率分別為91.3%、81.5%及48%。2例患者獲得II期手術(shù)切除。結(jié)論MWA聯(lián)合同步TACE治療大肝癌和巨塊型肝癌安全、有效,既可擴(kuò)大消融的適應(yīng)證,又能減少TACE栓塞劑的用量,是值得推廣的肝癌治療新模式。

肝癌;經(jīng)動(dòng)脈化療栓塞;微波消融;同步聯(lián)合治療;療效評(píng)價(jià)

肝細(xì)胞肝癌(hepatocellular carcinoma,HCC)是常見(jiàn)的惡性腫瘤,起病隱匿,僅20%～25%的患者適合手術(shù)切除[1]。經(jīng)動(dòng)脈化療栓塞(transarterial chemoembolization,TACE)是不能手術(shù)切除的中晚期HCC患者首選治療方法[2-5]。大肝癌和巨塊型肝癌由于動(dòng)脈血供豐富,TACE治療可取得一定的局部療效,但由于患者腫瘤負(fù)荷大,單次TACE治療療效有限,需多次重復(fù)TACE治療。即使經(jīng)多次TACE治療,大部分患者的腫瘤仍不能完全壞死,極易在治療期間出現(xiàn)肝內(nèi)和遠(yuǎn)處轉(zhuǎn)移,從而嚴(yán)重影響TACE的療效和患者生存期。因此,采用以TACE為基礎(chǔ)的聯(lián)合治療能進(jìn)一步提高大肝癌和巨塊型肝癌介入治療的療效。

腫瘤熱消融治療主要指射頻消融和微波消融(microwave ablation,MWA),具有操作簡(jiǎn)單、創(chuàng)傷小、對(duì)患者肝功能影響小及并發(fā)癥少的特點(diǎn),已成為直徑<3 cm的HCC根治性治療方法[6]。但對(duì)于大肝癌,消融治療很難使腫瘤完全壞死,尤其是邊緣部位容易殘留腫瘤組織。先采用TACE再序貫消融治療的聯(lián)合治療模式明顯優(yōu)于單一消融治療或TACE治療。Liu等[7]對(duì)比了TACE序貫MWA與單一TACE治療直徑>5 cm的HCC患者,發(fā)現(xiàn)聯(lián)合治療在病灶縮小率和生存期方面均明顯優(yōu)于單一 TACE 治療。Xu等[8]報(bào)道在直徑>5 cm的HCC治療中,TACE序貫聯(lián)合MWA治療能明顯延長(zhǎng)患者總體生存期和腫瘤疾病進(jìn)展時(shí)間。

目前國(guó)內(nèi)外尚未見(jiàn)到MWA同步聯(lián)合TACE治療大肝癌和巨塊型肝癌的報(bào)道。本文總結(jié)了65例接受MWA同步聯(lián)合TACE治療的大肝癌(直徑>5 cm)和巨塊型肝癌(直徑>10 cm)患者,探討該法治療大肝癌和巨塊型肝癌的安全性和有效性。

資 料 和 方 法

研究對(duì)象本研究經(jīng)復(fù)旦大學(xué)附屬中山醫(yī)院倫理學(xué)委員會(huì)批準(zhǔn)。收集自2013年3月至2014年12月在我院行 MWA 同步 TACE 治療的大肝癌和巨塊型肝癌患者。入選標(biāo)準(zhǔn):病理證實(shí)或符合肝癌臨床診斷標(biāo)準(zhǔn)的HCC患者且腫瘤直徑>5 cm[9];肝功能 Child A或B級(jí);ECOG(Eastern Cooperative Oncology Group)評(píng)分≤2分;無(wú)出血傾向、凝血功能正常或凝血功能障礙經(jīng)治療得以糾正者。排除標(biāo)準(zhǔn):彌漫型肝癌;合并門脈主干至二級(jí)分支癌栓或肝靜脈癌栓;合并活動(dòng)性感染,尤其是膽管系統(tǒng)炎癥等。

動(dòng)脈造影采用改良Seldinger 法行股動(dòng)脈穿刺,將5F或4F導(dǎo)管(RH,日本泰爾茂公司)插管至腹腔干或腸系膜上動(dòng)脈造影(德國(guó)拜爾先靈制藥有限公司),明確腫瘤大小、數(shù)目、分布以及供血情況。

超聲引導(dǎo)下MWA根據(jù)CT、MRI或超聲檢查,再結(jié)合肝動(dòng)脈造影確定擬消融病灶,消融主要針對(duì)肝內(nèi)主瘤病灶。B超(型號(hào)IPC-1530,日本ALOKA公司)引導(dǎo)下把微波針直接插入腫瘤內(nèi)并接近最遠(yuǎn)部,進(jìn)針選擇避開(kāi)大血管、膽管、膽囊和腸管的最短路徑,入路上至少應(yīng)有1 cm 的正常肝實(shí)質(zhì),開(kāi)啟電源,MWA儀(型號(hào)ECO-100C,南京億高醫(yī)療設(shè)備有限公司)采用水冷循環(huán)單極模式單極針,功率80～100 W,每個(gè)位點(diǎn)消融時(shí)間5～15 min,消融全程在B超監(jiān)測(cè)下進(jìn)行。前一位點(diǎn)消融結(jié)束后,根據(jù)消融情況退針2～4 cm至下一位點(diǎn)繼續(xù)消融,兩次消融區(qū)域要部分重合,上述過(guò)程重復(fù)進(jìn)行,直至瘤體完全被強(qiáng)回聲覆蓋?；颊咭话憔致榛蛉?根據(jù)腫瘤的大小及部位決定消融位點(diǎn)數(shù)和消融針用量,采用多灶重疊計(jì)算消融方案,一般采用雙針多點(diǎn)消融,凝固時(shí)間足夠,使壞死范圍加大。消融結(jié)束后電凝狀態(tài)下拔針,電凝穿刺道以防出血和穿刺道腫瘤種植。

再次肝動(dòng)脈造影消融后再次行肝動(dòng)脈造影,觀察消融結(jié)果、殘余病灶供血和腫瘤染色,有無(wú)造影劑外滲及肝動(dòng)脈-靜脈瘺等情況。針對(duì)殘留病灶行TACE治療,若出現(xiàn)造影劑外滲及肝動(dòng)脈-靜脈瘺等情況則進(jìn)一步行相應(yīng)的TACE治療。

TACE治療化療藥(奧沙利鉑50～150 mg,表阿霉素20～50 mg)、超液化碘油(3 ～ 20 mL,法國(guó)Guerbet制藥公司)及造影劑混合制成乳劑,通過(guò)微導(dǎo)管(商品名:Progreat,日本泰爾茂株式會(huì)社)注入殘余腫瘤供血?jiǎng)用},血流停滯時(shí)結(jié)束。對(duì)出現(xiàn)造影劑外滲、肝動(dòng)脈-靜脈瘺患者,給予合適粒徑的明膠海綿顆粒/栓塞微球(商品名:Embosphere,美國(guó)Biosphere Medical公司)或微彈簧圈栓塞,如果胸廓內(nèi)動(dòng)脈、膈動(dòng)脈等其他血管參與腫瘤供血,則同時(shí)進(jìn)行栓塞。

術(shù)后處理和隨訪術(shù)后24 h監(jiān)測(cè)生命體征,同時(shí)進(jìn)行保肝、堿化尿液、預(yù)防感染、營(yíng)養(yǎng)支持和止痛等治療。術(shù)后3～7天復(fù)查肝腎功能、電解質(zhì)、血常規(guī)以及平掃 CT,對(duì)消融程度和并發(fā)癥進(jìn)行評(píng)估。術(shù)后6～7周,患者復(fù)查肝功能、腫瘤標(biāo)志物(AFP、CEA、CA199等)以及增強(qiáng) CT 或MRI。按照改良的實(shí)體瘤療效評(píng)價(jià)標(biāo)準(zhǔn)(modified response evaluation criteria in solid tumor,m-RECIST)[10]評(píng)估療效,若術(shù)后復(fù)查未出現(xiàn)腫瘤復(fù)發(fā)或肝內(nèi)轉(zhuǎn)移,則患者每7～9周隨訪復(fù)查;若隨訪期間發(fā)現(xiàn)腫瘤壞死不完全或復(fù)發(fā),則根據(jù)患者具體情況再次行 TACE、MWA或 MWA 聯(lián)合 TACE。

結(jié)　　　果

患者一般資料共有65例(男55例,女10例)患者納入本次研究分析,其中AFP≥400 ng/mL42例,Child-Pugh A級(jí)52例,B級(jí)13例,腫瘤直徑≥10 cm 23例,術(shù)前合并動(dòng)靜脈瘺4例?；颊咭话阗Y料見(jiàn)表1。

表1　65例患者的臨床基本資料

術(shù)中并發(fā)癥所有患者均能耐受手術(shù),TACE碘油栓塞劑用量平均為8 mL(3～20 mL),栓塞后腫瘤染色基本消失(圖1)。消融后動(dòng)脈造影見(jiàn)造影劑外滲3例,給予明膠海綿和微彈簧圈栓塞后均消失(圖2),消融后新增動(dòng)靜脈瘺5例,給予明膠海綿栓塞后均消失。

術(shù)后并發(fā)癥術(shù)后3天內(nèi)21例患者出現(xiàn)輕至中度上腹部疼痛,經(jīng)對(duì)癥處理后緩解。部分患者出現(xiàn)不同程度的發(fā)熱、惡心、嘔吐和便秘,經(jīng)藥物對(duì)癥治療后緩解。2例患者消融穿刺點(diǎn)附近出現(xiàn)瘀斑,未經(jīng)特殊處理后痊愈。

術(shù)后3～7天復(fù)查CT,9例患者出現(xiàn)少量胸腔積液,均無(wú)呼吸困難等臨床癥狀,經(jīng)短時(shí)間觀察后積液均消失。65例患者術(shù)前丙氨酸氨基轉(zhuǎn)移酶(alanine aminotransferase,ALT)和天門冬氨酸氨基轉(zhuǎn)移酶(aspartate aminotransferase,AST)分別為(42.3±7.6)U/L和(67.3± 6.3)U/L,術(shù)后3天復(fù)查肝功能示ALT和AST為(150.3±82.0)U/L和135.3± 25.4)U/L,較術(shù)前均有明顯升高(P值分別為0.009和0.075);同步治療1個(gè)月后 ALT、AST 分別降至(32.3±4.2)U/L和(60.9 ±3.9)U/L(P值分別為0.074和0.092),差異無(wú)統(tǒng)計(jì)學(xué)意義。介入治療前后白蛋白和膽紅素差異無(wú)統(tǒng)計(jì)學(xué)意義(P值分別為0.42和0.36)。術(shù)后患者均未出現(xiàn)膽道損傷、周圍臟器損傷和肝腎功能衰竭等嚴(yán)重并發(fā)癥。

A:Contrast-enhanced CT showed a large lesion (15.2 cm×11.0 cm) in the right lobe of liver (arrow).B:Typical tumor staining was clearly demonstrated by angiography.C:Two 14-G antennas were showed under fluoroscopy in the MWA procedure.D:After MWA-TACE procedure,a selective angiography demonstrated complete devascularization of the targeted lesion.E:Axial contrast-enhanced CT scan obtained 3 month after combined treatment revealed tumor necrosis (arrow) and lipiodol deposition (star) in the location of original tumor.

圖134歲女性因肝右葉巨塊型肝癌行 DSA-B超引導(dǎo)下 MWA 同步聯(lián)合 TACE 治療

Fig 1MWA combined with TACE was performed on a 34-year-old female with large-size HCC in the right lobe of liver

臨床療效及生存期術(shù)前42例 AFP 升高患者中,手術(shù)1月后34例(81%)降至正常,7例有所下降(17%),1例增高。根據(jù) m-RECIST 標(biāo)準(zhǔn),完全緩解(complete response,CR)患者15例,部分緩解(partial response,PR) 46例,病情進(jìn)展(progress disease,PD) 4例,有效率為93.8%。本研究隨訪截止日期為2015年7月23日,隨訪時(shí)間2～21個(gè)月(中位隨訪時(shí)間13個(gè)月),65例患者存活52例,死亡13例,其中4例死于肝內(nèi)彌漫轉(zhuǎn)移和復(fù)發(fā),2例死于肝腫瘤破裂,3例死于肝腎功能衰竭,2例死于惡病質(zhì),1例死于全身轉(zhuǎn)移,1例死于腦梗死?；颊呖傮w無(wú)疾病進(jìn)展生存時(shí)間為(6.3±1.5)個(gè)月,中位生存時(shí)間為14個(gè)月,6、12及18個(gè)月的生存率分別為91.3%、81.5%及48%,2例患者經(jīng)同步治療后獲得II期手術(shù)切除,至隨訪截止日期未見(jiàn)腫瘤復(fù)發(fā)。

A:Contrast-enhanced CT showed a large lesion in the right lobe of liver.B:Angiography after MWA showed contrast agent extravasation (arrow).C:No abnormal tumor staining was displayed after TACE with gelatin sponge particles.

圖265歲女性因肝右葉巨塊型肝癌(直徑約10 cm)行DSA-B超引導(dǎo)下MWA同步聯(lián)合TACE治療

Fig 2MWA combined with TACE was performed on a 65-year-old female with large-size HCC in the right lobe of liver (diameter≈10 cm)

討　　　論

對(duì)于大肝癌和巨塊型肝癌,單純 TACE 常難以使腫瘤完全壞死,療效有限,患者易出現(xiàn)肝內(nèi)和遠(yuǎn)處轉(zhuǎn)移,長(zhǎng)期療效并不理想[11-12]。近年來(lái)熱消融成為除 TACE 治療外最常用的非手術(shù)治療方法,在小肝癌治療方面療效確切,可作為與外科手術(shù)、肝移植等同的根治性治療。與射頻消融相比,MWA具有導(dǎo)入能量更大、升溫效率更高、消融范圍相對(duì)更大、相同消融范圍所需時(shí)間更短、腫瘤局部滅活更徹底等優(yōu)點(diǎn),尤其對(duì)大肝癌和巨塊型肝癌,MWA治療具有更強(qiáng)的可操作性,省時(shí)、多針多點(diǎn)可達(dá)到更大消融范圍,使腫瘤滅活更徹底[13]。對(duì)于直徑≤3 cm 的肝癌,MWA與射頻消融都可以取得與手術(shù)切除相同的效果。對(duì)于直徑較大的腫瘤,難以保證腫瘤邊緣均達(dá)到壞死[14-16],易發(fā)生腫瘤殘存和復(fù)發(fā)轉(zhuǎn)移。對(duì)于大肝癌,MWA 完全消融率僅達(dá)69%～81.8%[17-18]。Liu等[19]報(bào)道直徑>5 cm的病灶經(jīng)MWA后局部復(fù)發(fā)率(40.9%)明顯高于直徑<5 cm的病灶(14%),兩者的局部復(fù)發(fā)率比較差異有統(tǒng)計(jì)學(xué)意義(P=0.026)。

MWA序貫聯(lián)合TACE治療HCC已被臨床證實(shí)療效顯著優(yōu)于單一MWA治療或TACE治療[7,20-22]。目前臨床上序貫聯(lián)合為先行 TACE 治療,2～4周后行單一MWA治療,TACE可使腫瘤組織血供減少,降低消融時(shí)熱量流失,擴(kuò)大腫瘤MWA的壞死范圍,但由于TACE與MWA之間有較長(zhǎng)的間隔時(shí)間,TACE治療后可能出現(xiàn)側(cè)支形成、血管再通等情況,因此序貫聯(lián)合不是嚴(yán)格意義上的即時(shí)性聯(lián)合治療,沒(méi)有充分發(fā)揮TACE與MWA之間的協(xié)同治療作用,并且單一MWA后缺乏DSA造影,不能及時(shí)發(fā)現(xiàn)并處理消融后出血等可能危及患者生命的嚴(yán)重并發(fā)癥。

本研究采用MWA同步聯(lián)合TACE的方式治療大肝癌(直徑>5 cm)和巨塊型肝癌(直徑>10 cm),即先行MWA治療再行TACE治療,取得了良好的臨床療效。同步治療先行MWA滅活大部分腫瘤,明顯減少了TACE時(shí)碘油和顆粒型栓塞劑及化療藥物的用量,減輕不良反應(yīng)和肝腎功能的損傷,MWA后行同步TACE所做得DSA造影,可進(jìn)一步明確消融后殘留腫瘤染色情況,靶向超選擇性插管于殘留腫瘤的供養(yǎng)動(dòng)脈分支行進(jìn)一步治療。本組65例患者經(jīng)MWA治療后 TACE 碘油栓塞劑用量均在20 mL以內(nèi)(平均 8 mL),碘油劑用量較單一 TACE 治療明顯減少。65例患者有效率(CR+PR)為93.8%?；颊呖傮w無(wú)疾病進(jìn)展生存時(shí)間為(6.3±1.5)個(gè)月,中位生存期14個(gè)月,6、12及18個(gè)月的生存率分別為91.3%、81.5%及48%,其中2例患者經(jīng)同步治療后獲得II期手術(shù)切除機(jī)會(huì),至隨訪截止日期未見(jiàn)腫瘤復(fù)發(fā)。另外,MWA同步聯(lián)合TACE治療能及時(shí)發(fā)現(xiàn)并處理消融后可能出現(xiàn)的并發(fā)癥(如出血、動(dòng)靜脈瘺等),本組65例患者消融后3例出現(xiàn)造影劑外滲,5例出現(xiàn)動(dòng)靜脈瘺,給予即時(shí)栓塞后均消失。因此,MWA同步聯(lián)合TACE治療能有效滅活腫瘤組織,減少TACE治療時(shí)栓塞劑和藥物的使用,減少因大劑量化療帶來(lái)的并發(fā)癥,患者獲益明顯。與單一TACE或MWA治療相比,MWA同步TACE治療可以有效地控制疾病進(jìn)展、延長(zhǎng)患者生存時(shí)間[23-25]。

本組病例同步治療后未見(jiàn)皮膚燒傷、出血、肝腎功能衰竭等嚴(yán)重并發(fā)癥,術(shù)中消融后肝動(dòng)脈造影見(jiàn)造影劑外滲3例,可能與術(shù)中穿刺有關(guān),給予即時(shí)栓塞后消失。術(shù)后大多數(shù)患者只有輕度肝功能受損、栓塞后綜合征(低熱、疼痛、呃逆等)、便秘及少量的胸腔積液,經(jīng)保肝、對(duì)癥藥物治療后均緩解。相比單一TACE或MWA,聯(lián)合治療的凝固性壞死更加徹底,肝繼發(fā)性膿腫的發(fā)生率更低。本組研究結(jié)果顯示MWA同步聯(lián)合TACE是安全的,與單一MWA或TACE比較并未明顯增加不良反應(yīng)及嚴(yán)重并發(fā)癥的發(fā)生率,與Liang等[26]和Ding等[27]的報(bào)道相仿。

綜上所述,MWA同步聯(lián)合TACE治療大肝癌和巨塊型肝癌安全、有效,與單一治療相比并未增加其他不良反應(yīng)及嚴(yán)重并發(fā)癥;同步治療可擴(kuò)大 MWA 的適應(yīng)證,及時(shí)處理 MWA 所致的并發(fā)癥(如出血、動(dòng)靜脈瘺),提高腫瘤壞死率、延長(zhǎng)患者總體生存期。本研究的不足之處:(1) 本研究為回顧性研究,隨訪時(shí)間短,不足以準(zhǔn)確地評(píng)價(jià)長(zhǎng)期療效;(2) 樣本量較小,可能對(duì)研究結(jié)果有一定影響。將來(lái)擬納入較多的樣本行多中心隨機(jī)對(duì)照研究。

[1]SIEGEL RL,MILLER KD,JEMAL A.Cancer statistics,2015[J].CA Cancer J Clin,2015,65(1):5-29.

[2]ZHANG L,YIN X,GAN YH,et al.Radiofrequency ablation following first-line transarterial chemoembolization for patients with unresectable hepatocellular carcinoma beyond the Milan criteria[J].BMC Gastroenterol,2014,14(1):11-17.

[3]MABED M,ESMAEEL M,EL-KHODARY T,et al.A randomized controlled trial of transcatheter arterial chemoembolization with lipiodol,doxorubicin and cisplatin versus intravenous doxorubicin for patients with unresectable hepatocellular carcinoma[J].Eur J Cancer Care (Engl),2009,18(5):492-499.

[4]LLOVET JM,REAL MI,MONTANA X,et al.Arterial embolisation or chemoembolisation versus symptomatic treatment in patients with unresectable hepatocellular carcinoma:a randomised controlled trial[J].Lancet,2002,359(9319):1734-1739.

[5]KOO JE,KIM JH,LIM YS,et al.Combination of transarterial chemoembolization and three-dimensional conformal radiotherapy for hepatocellular carcinoma with inferior vena cava tumor thrombus[J].Int J Radiat Oncol Biol Phys,2010,78(1):180-187.

[6]SHIOMI H,NAKA S,SATO K,et al.Thoracoscopy-assisted magnetic resonance guided microwave coagulation therapy for hepatic tumors[J].Am J Surg,2008,195(6):854-860.

[7]LIU C,LIANG P,LIU FY,et al.MWA Combined with TACE as a combined therapy for unresectable large-sized hepotocellular carcinoma[J].Int J Hyperthermia,2011,27(7):654-662.

[8]XU LF,SUN HL,CHEN YT,et al.Large primary hepatocellular carcinoma:transarterial chemoembolization monotherapy versus combined transarterial chemoembolization-percutaneous microwave coagulation therapy[J].J Gastroenterol Hepatol,2013,28(3):456-463.

[9]BRUIX J,SHERMAN M,AMERICAN ASSOCIATION FOR THE STUDY OF LIVER D.Management of hepatocellular carcinoma:an update[J].Hepatology,2011,53(3):1020-1022.

[10]LENCIONI R,LLOVET JM.Modified RECIST (mRECIST) assessment for hepatocellular carcinoma[J].Semin Liver Dis,2010,30(1):52-60.

[11]TAKAYASU K,ARII S,KUDO M,et al.Superselective transarterial chemoembolization for hepatocellular carcinoma.Validation of treatment algorithm proposed by Japanese guidelines[J].J Hepatol,2012,56(4):886-892.

[12]TERZI E,PISCAGLIA F,FORLANI L,et al.TACE performed in patients with a single nodule of hepatocellular carcinoma[J].BMC Cancer,2014,14(1):601-614.

[13]LENCIONI R,CROCETTI L.Local-regional treatment of hepatocellular carcinoma[J].Radiology,2012,262(1):43-58.

[14]GOLDBERG SN,GRASSI CJ,CARDELLA JF,et al.Image-guided tumor ablation:standardization of terminology and reporting criteria [J].J Vasc Int Radiol,2009,20(7 Suppl):S377-S390.

[15]QIAN GJ,WANG N,SHEN Q,et al.Efficacy of microwave versus radiofrequency ablation for treatment of small hepatocellular carcinoma:experimental and clinical studies[J].Eur Radiol,2012,22(9):1983-1990.

[16]ABDELAZIZ A,ELBAZ T,SHOUSHA HI,et al.Efficacy and survival analysis of percutaneous radiofrequency versus microwave ablation for hepatocellular carcinoma:an Egyptian multidisciplinary clinic experience[J].Surg Endosc,2014,28(12):3429-3434.

[17]JIAO DC,ZHOU Q,HAN XW,et al.Microwave ablation treatment of liver cancer with a 2,450-MHz cooled-shaft antenna:pilot study on safety and efficacy[J].Asian Pac J Cancer Prev,2012,13(2):737-742.

[18]POGGI G,MONTAGNA B,DI CESARE P,et al.Microwave ablation of hepatocellular carcinoma using a new percutaneous device:preliminary results[J].Anticancer Res,2013,33(3):1221-1227.

[19]LIU Y,ZHENG Y,LI S,et al.Percutaneous microwave ablation of larger hepatocellular carcinoma[J].Clin Radiol,2013,68(1):21-26.

[20]SEKI T,TAMAI T,NAKAGAWA T,et al.Combination therapy with transcatheter arterial chemoembolization and percutaneous microwave coagulation therapy for hepatocellular carcinoma[J].Cancer,2000,89(6):1245-1251.

[21]陳剛,唐曉軍,李宏波,等.肝動(dòng)脈化療栓塞聯(lián)合經(jīng)皮微波消融治療中晚期肝癌的療效評(píng)價(jià)[J].臨床放射學(xué)雜志,2012,31(5):710-713.

[22]GU L,LIU H,FAN L,et al.Treatment outcomes of transcatheter arterial chemoembolization combined with local ablative therapy versus monotherapy in hepatocellular carcinoma:a meta-analysis[J].J Cancer Res Clin Oncol,2014,140(2):199-210.

[23]NI JY,SUN HL,CHEN YT,et al.Prognostic factors for survival after transarterial chemoembolization combined with microwave ablation for hepatocellular carcinoma[J].World J Gastroenterol,2014,20(46):17483-17490.

[24]YIN XY,XIE XY,LU MD,et al.Percutaneous Thermal ablation of medium and large hepatocellular carcinoma long-term outcome and prognostic factors[J].Cancer,2009,115(9):1914-1923.

[25]FORNER A,REAL MI,VARELA M,et al.Transarterial chemoembolization for patients with hepatocellular carcinoma[J].Hepatol Res,2007,37(1):S230-S237.

[26]LIANG P,WANG Y,YU XL,et al.Malignant liver tumors:treatment with percutaneous microwave ablation-complications among cohort of 1136 Patients[J].Radiology,2009,251(3):933-940.

[27]DING J,JING X,LIU J,et al.Complications of thermal ablation of hepatic tumours:Comparison of radiofrequency and microwave ablative techniques[J].Clin Radiol,2013,68(6):608-615.

E-mail:wang.jianhua@zs-hospital.sh.cn

Microwave ablation combined with simultaneous transarterial chemoembolization for the treatment of large and massive hepatocellular carcinoma

SI Zeng-mei1,2, QIAN Sheng1,2, LIU Rong1,2, QU Xu-dong1,2, GONG Gao-quan1,2, WANG Xiao-lin1,2, YAN Zhi-ping1,2, WANG Jian-hua1,2△

(1Shanghai Institute of Medical Imaging,Shanghai 200032,China;2Department of Interventional Radiology, Zhongshan Hospital,Fudan University,Shanghai 200032,China)

ObjectiveTo assess the safety and efficacy of microwave ablation (MWA) combined with simultaneous transarterial chemoembolization (TACE) for large (diameter>5 cm) and massive (diameter>10 cm) hepatocellular carcinoma (HCC).MethodsWe reviewed the records of 65 patients with large or massive HCC treated with ultrasound-guided percutaneous MWA with simultaneous TACE between March 2013 and December 2014.The treatment procedure consisted of:initiative digital subtraction angiography (DSA),followed percutaneous MWA under ultrasound and subsequential angiography plus TACE.ResultsThe combination therapy was well tolerated in all patients with transitory hepatic and hematological toxicity and asymptomatic pleural effusion.Contrast agent extravasation was detected in 3 patients and dealt with embolization in time.There was no liver abscess,bile duct injury and other procedure related major complications.The average dosages of lipiodol were 8 mL.During the follow-up period (range 2-21 months),the mean progression-free survival time was (6.3±1.5) months.The median survival time was 14 months.The 6-,12- and 18-month overall survival rates were 91.3%,81.5%and 48%,respectively.Two patients underwent Ⅱ-stage surgical resection after immediate combination therapy.ConclusionsMWA combined simultaneous TACE therapy can be performed safely and effectively in patients without major complications for large and massive HCC.It enlarged the indications of MWA ,and was worth to be promoted.

hepatocellular carcinoma;transarterial chemoembolization;microwave ablation;simultaneous combination therapy;therapeutic evaluation

R735.7

Adoi: 10.3969/j.issn.1672-8467.2016.05.009

2016-01-05;編輯:段佳)