Kothary Nishita, Weintraub Joshua L, Susman Jonathan, Rundback John H
Division of Interventional Radiology, Stanford University Medical Center, 300 Pasteur Drive, Room H3652, Stanford, CA 94305-5642, USA.
J Vasc Interv Radiol. 2007 Dec;18(12):1517-26; quiz 1527. doi: 10.1016/j.jvir.2007.07.035.
Transarterial chemoembolization (TACE) has become a standard treatment option for patients with unresectable hepatocellular carcinoma (HCC). This retrospective study evaluated the safety and efficacy of TACE in patients at high risk with increased serum bilirubin level, low serum albumin level, poor hepatic reserve, or compromised hepatopetal flow in the portal vein (PV).
A total of 52 patients underwent 65 high-risk procedures. Thirty patients treated with 38 procedures (57.7% of patients and 58.5% of procedures) had serum bilirubin levels of 2-3 mg/dL (ie, moderate elevation) and 22 patients treated with 27 procedures (42.3% and 41.5%) had a serum bilirubin level of at least 3 mg/dL (ie, considerable elevation). Forty patients (76.9%) had serum albumin levels less than 3.5 mg/dL. Thirteen recipients of 15 procedures (25% and 20%) had portal diversion or obstruction. Twenty-four patients (46.2%) had a Child-Pugh (CP) score of 8 or less and 28 patients (53.8%) had a CP score of at least 9 at the time of TACE. Thirty patients (57.7%) had focal tumors and 22 patients (42.3%) had multifocal or infiltrative disease. Superselective chemoembolization could be performed in 37 procedures (56.9%); lobar chemoembolization was performed in the remaining 28 (43.1%).
The 30-day mortality rate was 7.7% and the procedure-related morbidity rate was 10.8%. Patients with multifocal disease and lobar embolization had significantly higher mortality rates (P=.03). Individual factors such as serum bilirubin, serum albumin, and PV flow did not affect outcomes significantly. The 1- and 2-year survival rates in patients with focal disease were 67.9% and 37.7%, respectively, compared with 19.6% and 0% in patients with multifocal disease (P<.0001).
TACE in patients considered at high risk does not necessarily incur a higher incidence of morbidity or mortality. Patient selection should be based on extent of disease, and these tumors should be treated selectively at a segmental level if possible.
经动脉化疗栓塞术（TACE）已成为无法切除的肝细胞癌（HCC）患者的标准治疗选择。本回顾性研究评估了TACE在血清胆红素水平升高、血清白蛋白水平降低、肝储备功能差或门静脉（PV）向肝血流受损的高危患者中的安全性和疗效。
共有52例患者接受了65次高危手术。30例患者接受了38次手术（占患者的57.7%，手术的58.5%），血清胆红素水平为2 - 3mg/dL（即中度升高），22例患者接受了27次手术（占42.3%和41.5%），血清胆红素水平至少为3mg/dL（即显著升高）。40例患者（76.9%）血清白蛋白水平低于3.5mg/dL。15例手术的13例接受者（占25%和20%）存在门静脉分流或阻塞。24例患者（46.2%）在TACE时Child-Pugh（CP）评分为8分或更低，28例患者（53.8%）CP评分至少为9分。30例患者（57.7%）有局灶性肿瘤，22例患者（42.3%）有多灶性或浸润性疾病。37次手术（56.9%）可进行超选择性化疗栓塞；其余28次（43.1%）进行了叶化疗栓塞。
30天死亡率为7.7%，手术相关发病率为10.8%。多灶性疾病和叶栓塞患者的死亡率显著更高（P = 0.03）。血清胆红素、血清白蛋白和PV血流等个体因素对预后无显著影响。局灶性疾病患者的1年和2年生存率分别为67.9%和37.7%，而多灶性疾病患者分别为19.6%和0%（P < 0.0001）。
高危患者的TACE不一定会导致更高的发病率或死亡率。患者选择应基于疾病范围，如果可能，这些肿瘤应在节段水平进行选择性治疗。
