本文選題：肝腫瘤 + 熱消融�。� 參考：《山東大學(xué)》2016年博士論文

【摘要】：影像引導(dǎo)的射頻消融(Radiofrequency ablation, RFA)和微波消融(Microwave Ablation, MWA)是目前臨床上治療肝癌的主要的熱消融方法,自上世紀(jì)90年代初射頻消融技術(shù)應(yīng)用于臨床以來,迅速發(fā)展為肝癌局部治療的一線治療方法。而隨著技術(shù)的革新及冷循環(huán)電極的應(yīng)用,微波消融在臨床的應(yīng)用也越來越廣泛。對(duì)于無法行手術(shù)治療的原發(fā)性肝癌或轉(zhuǎn)移性肝癌,射頻消融和微波消融均是目前肝癌局部治療的理想選擇,無論其臨床療效還是安全性均已有大宗病例和多中心研究報(bào)道。盡管RFA和MWA均為微創(chuàng)治療,且由于冷循環(huán)技術(shù)的應(yīng)用,嚴(yán)重并發(fā)癥發(fā)生率相對(duì)較低,但仍有一些嚴(yán)重并發(fā)癥,如腹腔內(nèi)出血、肝膿腫、出血、腸穿孔、氣胸、種植性轉(zhuǎn)移等。其中,肝膿腫為最常見的主要并發(fā)癥之一。臨床工作中,如何針對(duì)性選擇最合適的熱消融方法并減少并發(fā)癥對(duì)于肝癌的個(gè)體化治療尤為重要,本研究通過回顧性分析臨床病例資料,一方面探討經(jīng)皮冷循環(huán)RFA和MWA治療≤5cm肝癌的近遠(yuǎn)期療效和安全性,另一方面對(duì)行熱消融的肝腫瘤患者術(shù)后肝膿腫情況進(jìn)行分析,探討熱消融術(shù)后肝膿腫的發(fā)生率及風(fēng)險(xiǎn)因素。第一部分經(jīng)皮冷循環(huán)射頻消融與微波消融治療≤5cm原發(fā)性肝癌的療效及安全性比較[目的]探討經(jīng)皮冷循環(huán)射頻消融與冷循環(huán)微波消融治療≤5cm原發(fā)性肝癌的近遠(yuǎn)期療效及安全性差異。[方法]回顧性病例對(duì)照研究。收集2006年6月至2011年2月在山東大學(xué)齊魯醫(yī)院及威海市立醫(yī)院行冷循環(huán)RFA和MWA的原發(fā)性肝癌臨床資料齊全的病例共224例,男154例,女70例,其中RFA患者108例,MWA患者116例,符合單個(gè)腫瘤最大直徑≤5cm,或多個(gè)腫瘤數(shù)目≤3個(gè)且單個(gè)腫瘤最大直徑≤3cm; Child-Pugh分級(jí)A或B級(jí)；無門靜脈癌栓或肝外轉(zhuǎn)移；無嚴(yán)重心肝腎肺疾��；凝血酶原活動(dòng)度在40%以上；血小板≥50×109/L。采用局部麻醉或局部麻醉+靜脈麻醉,行超聲或CT引導(dǎo)下經(jīng)皮穿刺冷循環(huán)RFA和MWA,術(shù)后至少隨訪5年,通過增強(qiáng)CT或增強(qiáng)MR檢查評(píng)估消融效果,比較兩組患者局部療效、近遠(yuǎn)期生存率及并發(fā)癥,并分析累積生存率的影響因素。[結(jié)果]所有患者均成功應(yīng)用超聲或CT引導(dǎo)的經(jīng)皮肝穿刺RFA或MWA完成治療。兩組腫瘤完全消融率分別為91.1%VS 94.9%(χ2=0.12,P=0.88)。兩組總的局部復(fù)發(fā)率分別為8.1% VS 10.1%(χ2=0.25,P=0.70)；≤3cm的腫瘤RFA組和MWA組的局部復(fù)發(fā)率為4.2% VS 5.6%(χ2=0.23,P=0.63),3.1-5cm的腫瘤RFA組和MWA組的局部復(fù)發(fā)率為22.2% VS 8.3%(χ2=1.80,P=0.08)。兩組1、3、5年的無瘤生存率分別為84.3%、39.4%、16.6%,81.2%、40.5%、19.2%(log-rank檢驗(yàn)χ2=0.30,P=0.584)；總的累積生存率分別為97.2%、71.4%、41.1%,96.5%、74.2%、52.6%(log-rank檢驗(yàn)χ2=0.989,P=0.32)。亞組分析中,≤3cm肝癌患者兩組1、3、5年的無瘤生存率分別為86.2%、46.0%、17.1%,80.2%、39.4%、18.2%,(log-rank檢驗(yàn)χ2=0.003,P=0.959),累積生存率分別100%、87.3%、54.6%,97.1%、78.5%、52.4%(log-rank檢驗(yàn)χ2=0.191,P=0.662)。3.1-5cm肝癌患者兩組1、3、5年的無瘤生存率分別為78.2%、20.8%、16.4%,83.4%、44.1%、20.3%(log-rank檢驗(yàn)χ2=1.173,P=0.279)。累積生存率分別為97.2%、71.4%、41.1%,96.5%、74.2%、52.6%(log-rank檢驗(yàn)χ2=0.989,P=0.32)。RFA組和MWA組嚴(yán)重并發(fā)癥發(fā)生率分別為4.6% VS 2.6%(χ2=0.69,P=0.39)。MWA組的平均住院費(fèi)用(1.31±0.26萬元)要低于RFA組(1.92±0.38萬元)(P0.05)。Cox比例風(fēng)險(xiǎn)模型分析顯示消融方式、性別、年齡、肝功能Child-Pugh分級(jí)、合并肝硬化、特殊部位腫瘤、腫瘤個(gè)數(shù)、對(duì)患者無瘤生存的影響無統(tǒng)計(jì)學(xué)意義(P0.05),術(shù)前行肝動(dòng)脈化療栓塞(Transcatheter Arterial Chemoembolization, TACE)、術(shù)中與經(jīng)皮無水酒精注射(Percutaneous Ethanol Injection, PEI)聯(lián)合對(duì)累積生存的影響有統(tǒng)計(jì)學(xué)意義(P0.05)。[結(jié)論]經(jīng)皮冷循環(huán)RFA和MWA對(duì)于治療≤5cm肝癌的局部療效、遠(yuǎn)期療效和安全性均無明顯差異,嚴(yán)重并發(fā)癥發(fā)生率均低；對(duì)于3.1-5cm肝癌,MWA比RFA治療獲得更長的累積生存時(shí)間；術(shù)前行TAC E、術(shù)中與PEI聯(lián)合治療對(duì)RFA或MWA術(shù)后累積生存率有明顯影響；MWA治療的住院費(fèi)用要明顯低于RFA。第二部分肝腫瘤熱消融術(shù)后肝膿腫的發(fā)生率及風(fēng)險(xiǎn)因素探討[目的]探討肝腫瘤行熱消融術(shù)后肝膿腫發(fā)生率及風(fēng)險(xiǎn)因素。[方法]收集行RFA和MWA術(shù)共691例患者的臨床醫(yī)學(xué)資料,對(duì)患者基本特征、肝膿腫的發(fā)生率及風(fēng)險(xiǎn)因素進(jìn)行回顧性分析,并應(yīng)用t檢驗(yàn)及多因素Logistic回歸分析術(shù)后肝膿腫與風(fēng)險(xiǎn)因素之間的關(guān)系。[結(jié)果]結(jié)果：691例患者行RFA治療385例次,行MWA治療306例次,肝膿腫總發(fā)生率為1.7%,RFA組與MWA組肝膿腫的發(fā)生率分別為1.8%、1.6%,兩組間差異無統(tǒng)計(jì)學(xué)意義(P0.05)。Child-Pugh B、C級(jí)(P=0.0486)、患膽道疾病(P=0.0305)、糖尿病(P=0.0344)、第一肝門區(qū)腫瘤(P=0.0123)的患者術(shù)后肝膿腫發(fā)生率分別為4.0%、6.7%、6.5%、13.0%,上述四種因素組的患者與對(duì)照組比較差異有統(tǒng)計(jì)學(xué)意義(P0.05)；與PEI聯(lián)合治療組(P=0.0026)肝膿腫的發(fā)生率明顯低于未與PEI聯(lián)合治療組,差異有統(tǒng)計(jì)學(xué)意義(P0.05)。[結(jié)論]肝腫瘤熱消融治療后肝膿腫的總體發(fā)生率不高,Child-Pugh B、C級(jí)、患膽道疾病、糖尿病、第一肝門區(qū)腫瘤是其重要風(fēng)險(xiǎn)因素,選用RFA或MWA治療對(duì)熱消融術(shù)后肝膿腫形成的影響無差別,與PEI聯(lián)合治療有助于降低熱消融術(shù)后肝膿腫的發(fā)生率。
[Abstract]:Radiofrequency ablation (Radiofrequency ablation, RFA) and microwave ablation (Microwave Ablation, MWA) are the main heat ablation methods for the treatment of liver cancer at present. Since the application of radiofrequency ablation technology in the early 90s of the last century, it has rapidly developed into a first-line treatment for local treatment of liver cancer. As well as the application of cold circulatory electrodes, microwave ablation is becoming more and more widely used in clinical applications. For primary liver cancer or metastatic liver cancer that cannot be operated on, radiofrequency ablation and microwave ablation are the ideal choice for local treatment of liver cancer. RFA and MWA are minimally invasive, and the incidence of severe complications is relatively low due to the application of cold circulation technology. But there are still some serious complications, such as intraperitoneal bleeding, liver abscess, bleeding, intestinal perforation, pneumothorax, and implant metastasis. Among them, liver abscess is one of the most common major complications. Appropriate heat ablation and reduction of complications are particularly important for the individualized treatment of liver cancer. In this study, a retrospective analysis of clinical case data was conducted to investigate the near and long term efficacy and safety of percutaneous cold circulation RFA and MWA for the treatment of hepatocellular carcinoma (HCC). On the other hand, the liver abscess in patients with liver tumor after heat ablation was divided. Analysis of the incidence and risk factors of liver abscess after thermal ablation. The first part is the comparison of the efficacy and safety of percutaneous cold cycle radiofrequency ablation and microwave ablation in the treatment of primary hepatocellular carcinoma (5cm). [Objective] to explore the short-term and long term effects and safety differences of percutaneous cold circulatory radiofrequency ablation and cold circulation microwave ablation for the treatment of primary liver cancer (HCC). [Methods] a retrospective case control study was conducted. A total of 224 cases of primary liver cancer were collected from June 2006 to February 2011 in Qilu Hospital of Shandong University and Weihai Municipal Hospital of Shandong University. There were 154 cases of male and 70 women, including 108 cases of RFA and 116 cases of MWA, which accords with the maximum diameter of a single tumor less than 5cm, or multiple swelling. The number of tumors was less than 3 and the maximum diameter of single tumor was less than 3cm; Child-Pugh was A or B grade; no portal vein tumor thrombus or extrahepatic metastases; no serious heart and liver and kidney disease; prothrombin activity was above 40%; platelets more than 50 x 109/L. were treated with local anesthesia or local anesthesia + intravenous anesthesia, and CT guided percutaneous puncture cold circulation RFA and CT guided percutaneous puncture were performed. MWA was followed up for at least 5 years. The ablation effect was evaluated by enhanced CT or enhanced MR examination. The local efficacy, near long-term survival and complications were compared in the two groups, and the factors affecting the cumulative survival were analyzed. [results] all patients were successfully treated with ultrasound or CT guided percutaneous liver puncture RFA or MWA. The total ablation rate of the two groups of tumors. 91.1%VS 94.9% (x 2=0.12, P=0.88). The total local recurrence rates in the two groups were 8.1% VS 10.1% (x 2=0.25, P=0.70), and the local recurrence rate of group RFA and MWA < 3cm was 4.2% VS 5.6% (chi 2=0.23, P=0.63). The local recurrence rate was 22.2% 8.3% (chi square). The survival rates were 84.3%, 39.4%, 16.6%, 81.2%, 40.5%, 19.2% (log-rank test X 2=0.30, P=0.584), and the total cumulative survival rates were 97.2%, 71.4%, 41.1%, 96.5%, 74.2%, 52.6% (log-rank test Chi 2=0.989, P=0.32). Rank test Chi 2=0.003, P=0.959), the cumulative survival rate of 100%, 87.3%, 54.6%, 97.1%, 78.5%, 52.4% (log-rank test, 2=0.191, P=0.662) two group of.3.1-5cm liver cancer patients were 78.2%, 20.8%, 16.4%, 83.4%, 44.1%, 20.3% (log-rank test Chi 2=1.173, P=0.279), respectively. The incidence of severe complications in group 52.6% (log-rank test Chi 2=0.989, P=0.32) and MWA group was 4.6% VS 2.6% (x 2=0.69, P=0.39) in group.MWA (1.31 + 2 thousand and 600 yuan), which was lower than RFA group (1.92 + 3 thousand and 800 yuan) (1.92 + 3 thousand and 800 yuan) (P0.05).Cox proportional hazard model. The effects of sclerotherapy, special site tumor and number of tumors on the survival of the patients were not statistically significant (P0.05). The hepatic artery chemoembolization (Transcatheter Arterial Chemoembolization, TACE) was performed before operation, and the combined effect of intraoperative and percutaneous ethanol injection (Percutaneous Ethanol Injection, PEI) on cumulative survival was statistically significant (P0.05). [Conclusion] there is no significant difference in the local effect, long-term effect and safety of percutaneous cold cycle RFA and MWA for the treatment of 5cm liver cancer, and the incidence of severe complications is low. For 3.1-5cm liver cancer, MWA has a longer cumulative survival time than RFA; TAC E before operation and the cumulative survival rate after operation and PEI combined with PEI in the operation are clear. The hospitalization costs of MWA treatment were significantly lower than the incidence and risk factors of liver abscess after RFA. second liver tumor heat ablation. [Objective] to explore the incidence and risk factors of liver abscess after heat ablation of liver tumors. [Methods] the clinical medical data of 691 patients with RFA and MWA were collected, and the basic characteristics of the patients, liver, liver and liver abscess were collected. The incidence and risk factors of abscess were analyzed retrospectively, and the relationship between liver abscess and risk factors was analyzed by t test and multiple factor Logistic regression. [results] 691 cases were treated with RFA, 385 cases were treated with RFA, 306 cases were treated with MWA, the total incidence of liver abscess was 1.7%, and the incidence of liver abscess in group RFA and MWA group was 1.8, respectively. There was no statistically significant difference between the 1.6%, 1.6% and two groups (P=0.0486), C (P=0.0486), biliary tract disease (P=0.0305), diabetes (P=0.0344), and the first hepatic portal tumor (P=0.0123) in patients with postoperative liver abscess 4%, 6.7%, 6.5%, 13% respectively. The differences in the above four group were statistically significant (P0.05). The incidence of liver abscess in the combined treatment group (P=0.0026) with PEI was significantly lower than that in the non PEI group, and the difference was statistically significant (P0.05). [Conclusion] the overall incidence of liver abscess after heat ablation of liver tumor was not high, Child-Pugh B, C, biliary tract disease, diabetes, and the first hepatic portal tumor were the important risk factors, and RFA or MWA treatment was used. There is no difference in the effect of treatment on the formation of liver abscess after thermal ablation. Combined treatment with PEI can help reduce the incidence of liver abscess after thermal ablation.

【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2016
【分類號(hào)】：R735.7

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