例原发性肝癌的不同治疗手段的临床预后分析.doc

150例原发性肝癌的不同治疗手段的临床预后因素分析 研究生 牛永健 导师 包永星教授 新疆医科大学一附院肿瘤中心[摘要］ 目的：评价目前肝癌的三种常见治疗方法的生存率情况，以进一步探讨原发性肝癌治疗方式的最佳选择方法： 回顾性分析我院150例原发性肝癌的病历资料，其中，介入组（A组） 62例，行肝动脉插管栓塞化疗（transcatheter hepatic chemo-embolization TACE）；介入加手术组（TACE+surgery TACE+S）（B组）64例，行手术后介入治疗，部分肿块较大的病例先行介入，待分期降级或肿块缩小后再手术治疗，手术行肝叶或肝段切除，介入仍采用肝动脉插管栓塞化疗；介入加放疗组（C组）24例，介入后再行肿块局部三维适形放疗（3-dimensional conformal radiotherapy 3-DCRT)，介入仍采用肝动脉插管栓塞化疗，即TACE+3-DCRT组率的检验采用列联表χ2检验，生存分析用Kaplan-Meier法,生存率比较采用Log-rank检验。

结果：6月、1年、2年、3年生存率：介入组88.7％（55/62）、71％(44/62)、45.2％(20/44)、21.4%(6/28)；介入加手术组100％(64/64)、92.2％(59/64)、72.9％(43/59)、53.2％(25/47)；介入加放疗组100％(24/24)、83.3％(20/24)、60％(12/20)、46.7％(7/15)三组治疗方法生存率列联表χ2检验均有显著性差异（P<0.05）两两比较四格表χ2检验,A组与B组有显著性差异（P<0.05/3=0.0167）; 三组治疗方法生存分析Kaplan-Meier法检验有显著性差异（P=0.001），A、B和C组治疗方法的中位生存时间分别为24.3、43.9和31.6月，两两比较Log-rank检验,A组与B组有显著性差异（P=0.000）结论：原发性肝癌的治疗在以介入治疗基础上联合手术、放疗等综合治疗较单纯介入治疗的远期生存率明显提高,介入+手术组生存率明显高于其他两组，从生存曲线图来看，三种疗法生存率比较：介入联合手术组＞介入联合放疗组＞单纯介入组关键词：肝癌 TACE 综合治疗 生存率Clinical prognosis analysis with the different treatment modalities for primary liver cancer(PLC):a report of 150 casesNiu Yongjian Bao Yongxing Abstract: objective to evaluate survival rate condition of current three frequent treatment modalities for primary liver cancer,in order to discuss advancedly the best selection about therapy method for liver cancer .Methods: a retrospective analysis of 150 patients of PLC received three frequent treatments our hospital,among them ,62 cases which were included in intervention group were treated with transcatheter hepatic chemo-embolization ( TACE)（A group）;64 cases were in TACE+surgery(TACE+S) (B group),to go on intervention treatment after surgery,or in some cases with larger tumor, to go on intervention treatment before surgery, waiting tumor stage is downgraded,or tumor is contracted. To go on resection of liver lobe or segments of liver, intervention way is still transcatheter hepatic chemo-embolization; 24 cases included TACE+Radiotherapy(TACE+RT) (C group),after TACE,go on 3-dimensional conformal radiotherapy(3-DCRT) for hepatocellular local tumor.The test of rate uses Row-Column tables χ2 test, survival rates were assessed from the date of the beginning of treatment using the Kaplan-Meier method. The survival rates of three groups were compared using Log-rank. Results:6 monthes,1 year,2 years,3 years survival rate: 88.7％（55/62）、71％(44/62)、45.2％(20/44)、21.4%(6/28) in TACE group, 100％(64/64)、92.2％(59/64)、72.9％(43/59)、53.2％(25/47) in TACE+S group and 100％(24/24)、83.3％(20/24)、60％(12/20)、46.7％(7/15) in TACE+RT group. The Row-Column table χ2 tests of overall survival rates for three frequent treatment modalities were all significantly different（P<0.05）。

The 4th-Cell table χ2 tests of the 2-2 analysis among survival rates for three frequent treatment modalities were significantly different only between A and B group（P<0.05/3=0.0167）The survival analysis of three therapic groups using the Kaplan-Meier method was significantly different among A、B and C group（P=0.001）. Means for Survival Time among the A、B and C therapy groups were 24.3、43.9 and 31.6 monthes respectively The Log-Rank tests of the 2-2 analysis among three groups were significantly different only between A and B group（P=0.000）。

Conclusions:the survival rates of the TACE therapy combined with S or RT was significantly higher than the single TACE between the comprehensive treatments of PLC on the base of the TACE therapy. the survival rates of the TACE+S were greatly highest among three groups. According to survival plot, among the survival rates of three groups, TACE+S group> TACE+RT group> TACE group.【Key words】　Liver cancer TACE survival rates prognosis 前 言原发性肝癌是一种恶性程度很高的恶性肿瘤，严重危害着人类的生命健康，其发病率及死亡率有逐步升高的趋势。

据世界卫生组织2005年全球肿瘤统计分析表明，目前每年新患肝癌人数626000，死亡598000新患肿瘤病人中55%发生在中国，我国的肝癌诊治形势仍十分严峻[1,2]原发性肝癌的治疗方法较多,手术切除仍是原发性肝癌(primary liver cancer)(PLC)首选的治疗方法,但即使在发达国家,合并肝硬化的PLC患者适于根治性手术治疗者也仅占25%左右,而在手术患者中,每年又有约20%将会出现肝癌复发在一些西方国家,患者术后5年生存率为30%~50%在我国由于多数PLC患者同时合并有肝炎和肝硬化,因而生存率更低于单纯PLC的生存率[3~8]大多数病例发现时已无外科手术指征，不能手术切除的中晚期肝癌患者的平均生存期仅3～6个月[9]即使能切除，术后复发率也高达 60% 以上，因而，肝癌的整体治疗效果较差[10]肝动脉插管栓塞化疗(transcatheter hepatic chemo-embolization TACE)是目前公认的不能切除的原发性肝癌的重要治疗方法[11]虽然肝动脉灌注化疗（hepatic artery infusion chemotherapy HAI）和栓塞（hepatic artery embolization HAE）治疗不能手术切除的中晚期肝癌取得了良好的效果，已被公认为肝癌非手术疗法的首先方法，但是原发性肝癌的介入治疗的远期疗效并不理想[9]。

对于不能手术切除的中晚期原发性肝癌(PLC),肝动脉化疗栓塞(TACE)是常用的治疗手段,而常规外照射对肝癌的治疗作用极为有限因肝脏放射耐受性差(全肝照射耐受量<35 Gy),在既往的原发性肝癌治疗中很少单独使用放射治疗[12]目前多采用三维适行放疗（3-dimensional conformal radiotherapy 3-DCRT)，3DCRT是肿瘤放疗技术上的重大革新,可使放射高剂量区的立体分布和肿瘤的立体形态基本一致,在肝癌接受高剂量照射的同时显著减少正常肝组织和周边正常器官的受照剂量,从而提高中晚期肝癌姑息性放疗的效果[13]有文献报道我国新诊断出的肝癌患者中只有10%~15%适合手术近年来,随着三维适形放射治疗(3DCRT)的应用,结合经皮动脉化疗栓塞(TACE)已成为目前较好的一种治疗方法[14~16]本篇回顾性分析了新疆医科大学第一附属医院2005-5至2007-11肿瘤中心及普外科180例原发性肝癌的病历资料，随访到150例，随访率83.3％，现总结报告如下1 资料与方法：1．1 一般资料原发性肝癌150例，其中男性113例，女性37例，男：女约3.1：1；年龄29~82岁，其中≥60岁43.1%（65/150）,30~6。