本文選題：肝癌 + 門靜脈癌栓　； 參考：《第二軍醫(yī)大學(xué)》2017年碩士論文

【摘要】：研究背景和研究目的原發(fā)性肝癌是一種常見的惡性腫瘤。每年新增患者人數(shù)及死亡人數(shù)居高不下,肝癌細胞惡性程度高,進展快,侵襲性強,發(fā)現(xiàn)較晚。大多數(shù)患者發(fā)現(xiàn)時已處于中晚期。原發(fā)性肝癌發(fā)展為中晚期的一項重要特征就是癌細胞侵襲性生長入門靜脈,形成門靜脈癌栓。一旦形成門靜脈癌栓后,患者預(yù)后差,若無治療,生存期一般僅為3-6個月。門靜脈癌栓通常由門靜脈分支向主干侵襲,主干癌栓形成后易造成肝功能損害,頑固性腹水,食管胃底靜脈曲張破裂出血等。而目前尚沒有十分有效的治療門靜脈癌栓的方法。EASL指南認為索拉非尼治療是唯一的手段。本研究針對原發(fā)性肝癌侵犯門靜脈分支但尚未侵犯門靜脈主干的患者,通過兩種治療原發(fā)性肝癌合并門靜脈癌栓的方法:單純TACE治療及TACE聯(lián)合微波消融治療進行對比研究,以期待能夠改善這類患者的預(yù)后,為原發(fā)性肝癌侵犯門靜脈分支的治療提供一些新思路。研究方法本研究收集2014年1月至2014年12月曾在上海東方肝膽外科醫(yī)院住院治療的145例原發(fā)性肝癌伴門靜脈分支癌栓患者的臨床資料進行回顧性研究。以72例接受TACE聯(lián)合門靜脈分支癌栓微波消融治療的患者為治療組,以73例單純行TACE治療的患者為對照組。生存期隨訪及資料收集截止時間為2016年12月31日。通過對兩組患者的近期療效、生存時間及并發(fā)癥等進行對比分析,研究兩組治療效果有無差異,進一步對計數(shù)資料用百分率表示,組間率采用卡方檢驗;影響OS的單因素、多因素分析采用COX回歸分析,生存率采用Kaplan-Meier曲線法及l(fā)og-rank檢驗,并發(fā)癥及不良反應(yīng)等分類資料采用卡方檢驗,P0.05認為差異有統(tǒng)計學(xué)意義。結(jié)果1、兩組患者癌栓穩(wěn)定率DCR的比較治療組術(shù)后1個月癌栓穩(wěn)定率DCR為94.4%;對照組DCR為91.8%,P0.05。治療組術(shù)后3個月癌栓穩(wěn)定率DCR為86.1%;對照組DCR為68.5%,P0.05。治療組術(shù)后6個月癌栓穩(wěn)定率DCR為68.1%;對照組DCR為38.4%,P0.05。3個月及6個月兩組患者癌栓穩(wěn)定率DCR比較,有統(tǒng)計學(xué)意義。2、兩組患者生存時間比較治療組及對照組中位生存期分別為16.4個月和11.3個月,兩組間比較差異有統(tǒng)計學(xué)意義(P0.05)。對所有患者按照癌栓分型進行生存期分析,I型癌栓患者58例,中位生存時間為16.6個月;II型癌栓患者共87例,中位生存時間為14.3個月。不同癌栓分型生存時間有統(tǒng)計學(xué)差異(P=0.019)。治療組中,對不同癌栓類型生存期進行分析,I型癌栓28例,中位生存期為19.4個月;II型癌栓44例,中位生存期為16.4個月。兩組總體生存期P=0.417。提示無明顯統(tǒng)計學(xué)差異。共納入的145例患者中,初診發(fā)現(xiàn)為I型癌栓者共58例,治療組28例,中位生存時間為19.4個月;對照組30例,中位生存時間為16.6個月,兩組生存期比較無統(tǒng)計學(xué)差異(P=0.291)。初診發(fā)現(xiàn)為II型癌栓共87例,治療組44例,中位生存時間16.4個月;對照組43例,中位生存時間為9.7個月,兩組生存期比較有統(tǒng)計學(xué)差異(P=0.000)。3、通過分析發(fā)現(xiàn),PMWA治療、AFP水平、癌栓分型、原發(fā)灶最大直徑和腫瘤數(shù)目是單獨影響兩組患者生存期的主要因素。再把所有單因素納入多因素COX分析模型,進行比較發(fā)現(xiàn),是否經(jīng)PMWA治療、癌栓分型、腫瘤數(shù)目和原發(fā)灶最大直徑是影響患者生存時間的相對獨立因素。其中經(jīng)PMWA治療是保護因素,II型癌栓、腫瘤數(shù)目3個和腫瘤最大直徑5cm是危險因素。說明門靜脈癌栓經(jīng)PMWA治療可以降低這類患者死亡風(fēng)險,患II型門靜脈癌栓、腫瘤數(shù)目3個和腫瘤最大直徑5cm可增加這類患者死亡的風(fēng)險。4、兩組患者不良反應(yīng)的比較兩組患者不良反應(yīng)為發(fā)熱、局部肝區(qū)疼痛、惡心嘔吐、轉(zhuǎn)氨酶升高、總膽紅素升高等,未見統(tǒng)計學(xué)差異。治療組術(shù)后并發(fā)癥出現(xiàn)膽道熱損傷1例,消化道出血1例,動靜脈瘺形成2例;對照組術(shù)后并發(fā)癥出現(xiàn)腫瘤破裂出血1例,消化道出血1例,膽囊炎1例,穿刺點血腫1例�？赡芴崾痉种чT靜脈癌栓經(jīng)PMWA治療是一種較為安全的治療手段。結(jié)論1、對于原發(fā)性肝癌合并門靜脈分支癌栓的患者,動脈化療栓塞TACE聯(lián)合微波消融PMWA治療相比單純行動脈化療栓塞TACE治療,對延緩門靜脈癌栓由分支向主干侵犯進程有一定效果,達到為腫瘤治療的降期目的,給這類病人贏得更多的治療機會。2、對于原發(fā)性肝癌合并門靜脈分支癌栓的患者,動脈化療栓塞TACE聯(lián)合微波消融PMWA治療相比單純行動脈化療栓塞TACE治療,可以延長患者生存期。3、微波消融PMWA聯(lián)合動脈化療栓塞TACE治療相比單純TACE治療,沒有產(chǎn)生更多的不良反應(yīng)及并發(fā)癥,是一種相對安全的治療手段。
[Abstract]:Primary hepatocellular carcinoma (HCC) is a common malignant tumor. The number of newly added patients and death toll is high, the malignant degree of liver cancer is high, the progression is fast, and the invasiveness is strong. Most patients are found in the middle and late stages. The development of primary liver cancer is an important feature of the middle and late stages of cancer. Once the portal vein tumor thrombus is formed, the prognosis is poor and the survival time is only 3-6 months. The portal vein tumor thrombus is usually attacked by the portal vein to the main trunk, the main stem tumor thrombus is easily caused by the liver function damage, the intractable ascites, the esophagogastric varices bleeding and bleeding. But there is no very effective treatment for portal vein thrombus at present. The.EASL guide believes that Sola Fini therapy is the only means. This study is aimed at patients with primary liver cancer that invade the portal vein but have not yet violated the portal vein. Two methods of treatment for primary liver cancer with portal vein tumor thrombus are treated by simple TACE treatment and TACE Combined with microwave ablation, we hope to improve the prognosis of these patients and provide some new ideas for the treatment of portal vein branch of primary liver cancer. This study collected 145 cases of primary liver cancer hospitalized in Shanghai Oriental Hepatic Surgery Hospital from January 2014 to December 2014. The clinical data of patients with tumor thrombus were reviewed. 72 patients received TACE combined with portal vein branch thrombus microwave ablation were treated as the treatment group, and 73 patients treated with TACE were treated as the control group. The survival time follow-up and data collection cut-off time were in December 31, 2016. The short-term efficacy, survival time, and survival time of the two groups of patients were compared. The results of the complications were compared and analyzed. There were no differences in the treatment effect between the two groups. The percentage of the count data was further expressed, the rate of inter group was checked by chi square test, the single factor affecting the OS, the multiple factor analysis using the COX regression analysis, the survival rate using the Kaplan-Meier curve method and the log-rank test, and the complications and adverse reactions. The difference was statistically significant in the P0.05 test. Results 1, the stability rate of the tumor thrombus in the two groups was 94.4% in the comparison group 1 months after operation, 91.8% in the control group and 91.8% in the control group, and 86.1% in the P0.05. group 3 months after the operation. The DCR in the control group was 68.5%, and the cancer thrombus stability in the P0.05. treatment group was 68.1% after the operation for 6 months, and 68.1%. In group DCR of 38.4%, P0.05.3 months and 6 months, the stability of cancer thrombus was compared with DCR, with a statistically significant.2. The median survival time of the two groups was 16.4 months and 11.3 months in the comparison group and the control group, respectively. The difference between the two groups was statistically significant (P0.05). The survival period of all patients was analyzed according to the tumor thrombus classification. There were 58 patients with type I tumor thrombus, with a median survival time of 16.6 months; a total of 87 patients with type II tumor thrombus, with a median survival time of 14.3 months. The survival time of different type of tumor embolus was statistically different (P=0.019). In the treatment group, the survival time of different type of tumor embolus was analyzed, 28 cases of type I tumor thrombus, the median survival period of 19.4 months, 44 cases of II type tumor thrombus and middle birth. The survival period was 16.4 months. There were no significant statistical differences in the total survival time of the two groups. Of the 145 patients, the first diagnosis was found in 58 cases of type I tumor thrombus, 28 in the treatment group and 19.4 months in the median survival time; 30 cases in the control group, with a median survival time of 16.6 months, and no statistical difference in the survival period of the two groups (P=0.291). The first diagnosis was found. There were 87 cases of type II tumor thrombus and 44 cases in the treatment group, with a median survival time of 16.4 months, and 43 cases in the control group with a median survival time of 9.7 months. The two groups had a statistical difference (P=0.000).3. The analysis found that the PMWA treatment, the AFP level, the tumor thrombus type, the maximum diameter of the primary focus and the number of tumors were the main factors affecting the survival period of the two groups of patients. Factors. All single factors were included in the multifactor COX analysis model. It was found that PMWA treatment, tumor emboli, the number of tumors and the maximum diameter of the primary focus were the relative independent factors affecting the patient's survival time. The PMWA therapy was a protective factor, the II type tumor thrombus, the 3 tumor number and the tumor maximum diameter 5cm were the risk factors. PMWA treatment can reduce the risk of death in this type of patients with portal vein tumor thrombus, II type of portal vein tumor thrombus, 3 tumor number and the maximum tumor diameter 5cm can increase the risk of death in this type of patients, the two group of patients with adverse reactions are two groups of patients with fever, local liver pain, nausea and vomiting, elevated aminotransferase, total bile. There were 1 cases of biliary tract heat injury in the treatment group, 1 cases of gastrointestinal bleeding, 2 cases of arteriovenous fistula formation, 1 cases of hemorrhage and hemorrhage in the control group, 1 cases of hemorrhage in the digestive tract, 1 cases of cholecystitis and 1 cases of puncture point hematoma in the control group, which could suggest that the PMWA treatment of the branch portal vein tumor thrombus is a more effective method. Conclusion 1, for patients with primary liver cancer with portal vein branch tumor thrombus, arterial chemoembolization TACE combined with microwave ablation PMWA treatment compared with pure action pulse chemoembolization TACE treatment, to postpone the portal vein tumor thrombus from the branch to the main course of invasion of the process has certain effect, to achieve the goal of the tumor treatment of this kind of reduction. Patients won more opportunities for treatment,.2, for patients with primary liver cancer with portal vein branch tumor thrombus, arterial chemoembolization TACE combined with microwave ablation PMWA therapy can prolong the patient's survival.3 compared with pure action pulse chemotherapy embolization TACE, and microwave ablation PMWA combined with arterial chemoembolization TACE treatment compared with pure TACE therapy, It is a relatively safe treatment to produce more adverse reactions and complications.
【學(xué)位授予單位】：第二軍醫(yī)大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R735.7

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