巨块型肝内胆管癌术后经肝动脉化疗栓塞的有效性

doi:10.16139/j.1007-9610.2021.02.010

摘要/Abstract

摘要：

目的：探讨巨块型肝内胆管癌术后经肝动脉化疗栓塞（transarterial chemoembolization,TACE）治疗的有效性。方法：回顾性分析2009年1月至2013年12月手术治疗125例巨块型肝内胆管癌（最大径≥10 cm）病人的临床病理资料。35例术后TACE,90例无术后TACE,分别为TACE组和非TACE组。采用Kaplan-Meier法估计病人术后复发率和生存率。采用Log-Rank检验比较组间差异。应用Cox回归探索影响病人术后复发和生存的独立危险因素。采用倾向评分匹配减少组间差异。根据肝内胆管癌第8版TNM分期进行亚组分析,探索术后TACE治疗的获益病人。结果：TACE组和非TACE组具有相似的复发率和生存率（5年复发率：85.7%比84.4%,P=0.487;5年生存率：22.9%比20.0%,P=0.426）。1∶1倾向评分配对后,两组各33例病人,术后复发率（P=0.114）和生存率（P=0.197）差异无统计学意义。TNM分期亚组分析,61例TNM Ⅰ期,64例TNM Ⅱ期。分期分析显示Ⅰ期病人TACE组和非TACE组的复发率和生存率差异无统计学意义。Ⅱ期病人TACE组5年复发率较低（91.7%比97.5%,P=0.022）,5年生存率较高（12.5%比2.5%,P=0.002）。在矫正肿瘤多发、血管侵犯和癌胚抗原≥5 μg/L后,TACE仍是显著影响Ⅱ期病人肿瘤复发（风险比：0.564,95% CI：0.327~0.974）和生存（风险比：0.449,95% CI：0.259~0.777）的危险因素。结论：术后TACE有可能改善巨块型肝内胆管癌TNM Ⅱ期病人的预后。

关键词: 巨块型肝内胆管癌, 经肝动脉化疗栓塞, 远期生存, TNM分期

Abstract:

Objective To investigate the effect of postoperative transarterial chemoembolization (TACE) for huge intrahepatic cholangiocarcinoma (ICC). Methods Data of 125 huge ICC (diameter ≥10 cm) patients with surgical treatment treated with or without TACE (TACE group 35 cases, and non-TACE group 90 cases) between January 2009 and December 2013 were analyzed retrospectively. Both recurrence rate and overall survival (OS) rate were analyzed using the Kaplan-Meier method and the difference using Log-Rank test. Cox regression analysis was used to explore the independent risk factors of postoperative recurrence and OS. Propensity score matching was used to reduce the difference between groups. Subgroup analysis was done for benefited patients from TACE based on the 8th TNM staging of ICC. Results TACE group had similar recurrence and OS with non-TACE group. 5-year recurrence rate and OS rate were 85.7% vs. 84.4%, P=0.487; 22.9% vs. 20.0%, P=0.426, respectively. After 1∶1 propensity score matching with 33 cases each group, there was no significant difference between two groups (P=0.114 for recurrence, P=0.197 for OS). According to TNM sta-ging, there were 61 cases in stage Ⅰ and 64 cases in stage Ⅱ. Staging analysis showed that TACE group and non-TACE groups yielded similar recurrence and OS in patients with stage Ⅰ. However, for patients in stage Ⅱ, TACE group had lower recurrence rate (91.7% vs. 97.5%, P=0.022) and higher OS rate (12.5% vs. 2.5%, P=0.002). After adjustment for multiple tumors, vascular invasion, and CEA ≥5 μg/L, TACE was independent risk factor of recurrence (hazard ratio: 0.564, 95%CI: 0.327-0.974) and OS (hazard ratio: 0.449, 95%CI: 0.259-0.777) in patients with stage Ⅱ. Conclusions For patients with huge ICC, postoperative TACE may improve the prognosis of patients with TNM stage Ⅱ.

Key words: Huge intrahepatic cholangiocarcinoma, Transarterial chemoembolization, Long-term prognosis, TNM staging

中图分类号:

R735.8

司安锋, 雷正清, 杨平华, 江涛, 王轩, 程张军. 巨块型肝内胆管癌术后经肝动脉化疗栓塞的有效性[J]. 外科理论与实践, 2021, 26(02): 138-143.

SI Anfeng, LEI Zhengqing, YANG Pinghua, JIANG Tao, WANG Xuan, CHENG Zhangjun. Effectiveness of postoperative transarterial chemoembolization for huge intrahepatic cholangiocarcinoma[J]. Journal of Surgery Concepts & Practice, 2021, 26(02): 138-143.

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变量	TACE组（n=35）	非TACE组（n=90）	P值
年龄（岁）	54 (47~64)	55 (46~62)	0.835
男性	21 (60.0)	52 (57.8)	0.821
有结石	5 (14.3)	18 (20.0)	0.459
乙肝表面抗原阳性	17 (48.6)	38 (42.2)	0.521
甲胎蛋白≥20 μg/L	11 (31.4)	18 (20.0)	0.174
糖类抗原19-9≥39 U/L	15 (42.9)	45 (50.0)	0.473
癌胚抗原≥5 μg/L	5 (14.3)	25 (27.8)	0.113
总胆红素≥17.1 μmol/L	3 (8.6)	17 (18.9)	0.254
丙氨酸转氨酶≥44 U/L	6 (17.1)	13 (14.4)	0.706
碱性磷酸酶≥129 U/L	10 (28.6)	34 (37.8)	0.333
肿瘤直径（cm）	11.1 (10.4~13.3)	11.7 (10.4~13.0)	0.839
肿瘤数目
多发	17 (48.6)	34 (37.8)	0.270
单发	18 (51.4)	56 (62.2)
肝硬化	9 (25.7)	20 (22.2)	0.678
术中输血	14 (40.0)	26 (28.9)	0.232
分化差	2 (5.7)	5 (5.6)	1.000
血管侵犯	11 (31.4)	14 (15.6)	0.046
TNM分期
Ⅰ: T_1bN₀M₀	11 (31.4)	50 (55.6)	0.015
Ⅱ: T₂N₀M₀	24 (68.6)	40 (44.4)

变量	单因素		多因素
变量	风险比（95% CI）	P值	风险比（95% CI）	P值
年龄（岁）55>比≤55	0.950 (0.646~1.397)	0.794
男比女	0.973 (0.659~1.439)	0.893
结石	1.023 (0.628~1.667)	0.927
乙肝表面抗原阳性	1.053 (0.714~1.552)	0.795
甲胎蛋白（μg/L）>20比≤20	1.297 (0.835~2.013)	0.247
糖类抗原19-9（U/L）>39比≤39	1.372 (0.931~2.022)	0.110
癌胚抗原（μg/L）>5比≤5	2.346 (1.518~3.627)	<0.001	1.804 (1.142~2.850)	0.011
总胆红素（μmol/L）>17.1比≤17.1	1.101 (0.654~1.852)	0.718
丙氨酸转氨酶（U/L）>44比≤44	0.977 (0.573~1.666)	0.931
碱性磷酸酶（U/L）>129比≤129	1.187 (0.794~1.774)	0.404
肿瘤多发	2.212 (1.490~3.284)	<0.001	1.857 (1.229~2.807)	0.003
肝硬化	1.001 (0.634~1.580)	0.998
术中输血	1.299 (0.861~1.959)	0.212
分化差	1.451 (0.635~3.317)	0.377
血管侵犯	1.871 (1.181~2.964)	0.008	1.871 (1.164~3.007)	0.010
TACE	0.840 (0.547~1.291)	0.427

变量	单因素		多因素
变量	风险比（95%CI）	P值	风险比（95%CI）	P值
年龄（岁）55>比≤55	0.893 (0.612~1.301)	0.555
男比女	1.082 (0.738~1.585)	0.687
结石	0.804 (0.495~1.307)	0.380
乙肝表面抗原阳性	1.158 (0.794~1.687)	0.446
甲胎蛋白（μg/L）>20比≤20	1.762 (1.138~2.729)	0.011
糖类抗原19-9（U/L）>39比≤39	1.210 (0.832~1.759)	0.319
癌胚抗原（μg/L）>5比≤5	1.555 (1.015~2.382)	0.042
总胆红素（μmol/L）>17.1比≤17.1	0.866 (0.509~1.473)	0.596
丙氨酸转氨酶（U/L）>44比≤44	1.131 (0.682~1.877)	0.633
碱性磷酸酶（U/L）>129比≤129	1.268 (0.585~1.876)	0.234
肿瘤多发	1.927 (1.315~2.826)	0.001	1.885 (1.285~2.765)	0.001
肝硬化	0.943 (0.594~1.498)	0.805
术中输血	1.297 (0.872~1.930)	0.199
分化差	1.330 (0.583~3.034)	0.498
血管侵犯	2.536 (1.600~4.020)	<0.001	2.748 (1.711~4.412)	<0.001
TACE	0.862 (0.566~1.312)	0.488

变量	TACE组（n=33）	非TACE组（n=33）	P值
年龄（岁）	54.0 (46.5~64.5)	56.0 (46.5~62.5)	0.768
男性	19 (57.6)	19 (57.6)	1.000
有结石	5 (15.2)	4 (12.1)	1.000
乙肝表面抗原阳性	15 (45.5)	17 (51.5)	0.622
甲胎蛋白≥20 μg/L	9 (27.3)	8 (24.2)	0.778
糖类抗原19-9≥39 U/L	13 (39.4)	16 (48.5)	0.457
癌胚抗原≥5 μg/L	5 (15.2)	3 (9.1)	0.706
总胆红素≥17.1 μmol/L	3 (9.1)	2 (6.1)	/
丙氨酸转氨酶≥44 U/L	5 (15.2)	6 (18.2)	0.741
碱性磷酸酶≥129 U/L	9 (27.3)	11 (33.3)	0.592
肿瘤直径（cm）	11.1 (10.5~13.5)	11.5 (10.3~12.3)	0.620
肿瘤数目
多发	16 (48.5)	14 (42.4)	0.621
单发	17 (51.5)	19 (57.6)
肝硬化	7 (21.2)	6 (18.2)	0.757
术中输血	13 (39.4)	7 (21.2)	0.108
分化差	2 (6.1)	2 (6.1)	/
血管侵犯	9 (27.3)	7 (21.2)	0.566
TNM分期
Ⅰ: T_1bN₀M₀	11 (33.3)	14 (42.2)	0.447
Ⅱ: T₂N₀M₀	22 (66.7)	19 (57.6)