【作者】 黄鹏；

【导师】 倪才方；

【作者基本信息】 苏州大学 ， 影像医学与核医学（专业学位）， 2021， 硕士

【摘要】 目的:通过与CT引导微波消融(Microwave Ablation,MWA)比较,评估经动脉化疗栓塞(Transarterial Chemoembolization,TACE)联合锥体束 CT(Cone-beam CT,CBCT)引导同步MWA治疗直径小于3厘米肝细胞癌(Hepatocellular Carcinoma,HCC)的有效性及安全性。材料及方法:回顾性研究2018年3月至2020年1月接受MWA治疗和TACE联合MWA治疗92例直径小于3cm HCC患者的资料。纳入标准主要为:(1)临床或病理诊断为HCC;(2)局部未经治疗小于3cm的HCC,且无肝外转移或血管侵犯;(3)拒绝或不适合接受外科手术;(4)接受TACE联合CBCT引导同步MWA或单独CT引导MWA治疗。排除标准主要为:(1)患者ECOG评分≥2分或Child-Pugh评分≥10分;(2)1月内有食管胃曲张静脉破裂出血,或预计生存期小于3月;(3)存在TACE或MWA的禁忌证,例如不可纠正的凝血功能异常或障碍、碘对比剂过敏及器官功能衰竭等;(4)随访期内接受系统治疗;(5)患者失访或随访资料不完整。根据治疗方法分为A组(患者接受TACE联合CBCT引导同步MWA治疗)和B组(患者接受CT引导MWA治疗)。比较两组的操作成功率、肿瘤反应、手术相关并发症及术后不良反应的发生情况。应用改良版实体肿瘤反应评估标准(mRECIST)评估局部肿瘤反应;应用不良事件评价标准5.0版(CTCAE v5.0)评估手术并发症及不良反应。采用SPSS 23.0统计学软件对两组的各项数据进行对比分析,以P<0.05认定为差异具有统计学意义。结果:本研究共纳入62例患者(65枚结节),其中A组30例(31枚结节)、B组32例(34枚结节)。两组的基线特征(例如年龄、性别、肝硬化病因、既往治疗史、巴塞罗那分期、Child-Pugh评分、ALBI评分、病灶直径、AFP、DCP)无统计学差异。中位随访时间为15.6个月(95%置信区间:14.28月-17.56月)。两组的手术操作成功率均为100%。A组碘油乳剂的平均用量为4.6mL。A组消融平均时间及平均功率为7.0分钟、56.1W,B组为7.3分钟、58.1W。在短期疗效方面,A组的首次CR率高于B组[96.8%(30/31)vs 76.5%(26/34),P=0.028]。两组的9例残余病灶均经CT引导的二次MWA达到CR。术后1、3、6、12月的局部客观反应率(CR+PR),A组均为100%,B组分别为94.3%、100%、100%、97.1%。两组患者术后1月的AFP值、DCP值均较术前显著下降(AFP:A组,P=0.008;B组,P=0.016;DCP:A组,P=0.028;B组,P=0.026)。两组患者1年内的局部肿瘤进展发生率无统计学差异(A组vs B组:3.2%vs 11.8%,P=0.358)。两组患者1年内的肝内远处复发的发生率无统计学差异(A组vs B组:20.0%vs 21.9%,P=1.000),且均未出现肝外转移。A组31枚结节中,16枚术前平扫CT显示不清,其首次CR率为100%;13枚位于膈顶部,其首次CR率为92.3%(12/13)。A组中,7例(23.3%)出现了严重不良反应,包括1例大于5倍的AST升高、3例大于5倍的ALT升高、1例大于3倍的TBIL升高、2例血小板减少(<50×109/L)、1例严重肝动脉-门静脉瘘、1例严重肝脏出血。术中即刻造影发现2例血管损伤并成功栓塞。B组中,5例(15.6%)出现了严重不良反应,其中包括1例大于5倍的AST升高、3例大于5倍的ALT升高、1例严重肝脏出血、1例严重血胸。2例出血患者转运至DSA室后成功栓塞。两组的严重不良反应发生率无统计学差异(23.3%vs 15.6%,P=0.443),均未产生严重不良后果。结论:与CT引导MWA相比,TACE联合锥体束CT引导同步MWA的“一站式”方法治疗直径小于3cm HCC,可以达到更高的完全消融率。该方法安全可行,可成为无法行CT引导消融患者的替代治疗方法。更多还原

【Abstract】 Objective:To investigate the efficacy and safety of transarterial chemoembolization(TACE)combined with cone-beam CT(CBCT)guided microwave ablation(MWA)in a single session for hepatocellular carcinoma(HCC)<3 cm.Material and method:This retrospective study concentrated on the 92 patients with HCC(<3 cm)treated with MWA alone or TACE combined with MWA from March 2018 to January 2020.The inclusion criteria were as follows:(1)diagnosis of HCC confirmed by pathologic results or following the non-invasion criteria;(2)treatment-naive(locoregional)nodules smaller than 3 cm without vascular invasion or extrahepatic metastases;(3)patient refusal or unfitness for curative resection;and(4)patient received TACE combined with CBCT-guided MWA in a single session or CT-guided MWA alone.The exclusion criteria were as follows:(1)ECOG status≥ 2 or Child-Pugh C liver profile;(2)gastroesophageal varices bleeding within 1 month or expected survival time less than 3 month;(3)contra-indications to TACE and MWA ablation(such as uncorrectable blood coagulation dysfunction,allergic to iodine contrast agent,organ dysfunction,etc.);(4)patients received systematic therapy during the follow-up;and(5)patient follow-up data was incomplete or lost to follow-up.According to the treatment method,th(?)patients were divided into 2 groups.Patients in Group A received TACE combined with CBCT-guided MWA in a single session and patients in Group B received CT-guided MWA alone.The technical success rate,local tumor response,procedure-related complications and adverse events(AEs)was compared.The modified Response Evaluation Criteria in Solid Tumors(mRECIST)and the Common Terminology Criteria for Adverse Events v5.0(CTCAE v5.0)was adopted to assess the local tumor response,the procedure-related complications and AEs,respectively.Results:62 patients with 65 HCC nodules were enrolled in the present study:30 cases(with 31 HCC nodules)in group A and 32 cases(with 34 HCC nodules)in group B.The baseline characteristics were similar between two groups.The median follow-up time was 15.6 months(95%CI:14.28-17.56 months).The technical success rate was both 100%in group A and B.In group A,the mean dosages of iodized oil emulsion used were 4.6mL.The mean duration of ablation and the mean microwave power were 7.0 minutes and 56.1 W in group A,and 7.3 minutes and 58.1W in group B,respectively.In terms of the short-term efficacy,the initial CR rate were higher in group A than in group B[96.8%(30/31)vs 76.5%(26/34),P=0.028].All 9 residual unablated tumors were successfully treated by secondary CT-guided MWA and the tumor response was CR.For the local tumor response,the ORRs(CR+PR)of group A at 1 month,3 months,6 months and 12 months were 100.0%.The ORRs of group B at 1 month,3 months,6 months and 12 months were 94.3%,100.0%,100.0%,and 97.1%,respectively.A significant decrease of the AFP was observed after the procedure in group A and B(group A,P=0.008;group B,P=0.016),so was the DCP(group A,P=0.028;group B,P=0.026).There was no statistical difference in the LTP rate in 1 year between group A and B(3.2%vs 11.8%,P=0.358).Besides,there was no statistical difference in the incidence of intrahepatic recurrence in 1 year between the two groups(group A vs group B:20.0%vs 21.9%,P=1.000)and none of the patients in both group experienced extra-hepatic metastasis.In group A,for the 16 nodules which were invisible in pre-procedural CT plain scan,the initial CR rate was 100%.For the 13 nodules located in the liver dome,the initial CR rate was 92.3%(12/13).Severe AEs occurred in 7(23.3%)patients in group A,including 1 with increased AST,3 with increased ALT,1 with hyperbilirubinemia,2 with thrombocytopenia,1 with arterio-portal fistula and 1 with hepatic bleeding.Meanwhile,Severe AEs occurred in 5(15.6%)patients in group B,including 1 with increased AST,3 with increased ALT,1 with hepatic bleeding,and 1 with hemothorax.There was no statistically significant difference in the incidence of severe AEs between group A and B(23.3%vs 15.6%,P=0.443)and all the AEs were successfully controlled after conservative or embolization treatment.Conclusions:Compared with CT-guided MW A,TACE combined with CBCT-guided MWA in a single session can provided a higher initial CR rate with an acceptable safety profile for HCC<3 cm.It could be an alternative treatment for HCC infeasible for CT-guided ablation.更多还原