| Hepatocellular carcinoma(HCC)is one of the most common malignant tumors,the incidence is fifth of malignant tumors in the world,while the mortality is third.In China,according to the National Cancer Center's latest cancer report published in 2018,the incidence of liver cancer was forth of malignant tumors,and the mortality rate is the second highest.In recent years,with the advancement of medical technology and study on the pathophysiological mechanism of hepatocellular carcinoma,great progress has been made in the diagnosis and treatment but the survival prognosis of patients with hepatocellular carcinoma is still needed to be improved.Hepatocellular carcinoma has higher recurrence,metastasis rate,and poor prognosis.The reason is its high degree of malignancy.Another important reason is the extremely easy invasion to the portal vein.Portal vein tumor thrombus(PVTT)is formed and metastasized to intrahepatic or extrahepatic with blood vessels.It has been reported that the incidence of PVTT is as high as 44.0%~62.2%.If the treatment is not timely,the patient's natural survival is only 2.7 to 4.0 months.For patients with hepatocellular carcinoma and portal vein tumor thrombus,there is currently no uniform treatment consensus in the world.In Western countries,the treatment of patients with liver cancer and portal vein thrombosis is more conservative.According to the previous Barcelona guide of 2018,Solafini is the only recommended treatment,and the 2018 Barcelona guide only makes Solafini as systemic treatment.However,East Asian countries including China are relatively active,and gradually formed a consensus based on surgical treatment,combined with chemoembolization,Ablation,targeted therapy,chemotherapy,radiotherapy,immunotherapy,and traditional Chinese medicine treatment.At present,surgical resection is still the preferred or main treatment for liver cancer with PVTT.Surgery,including tumor resection and tumor thrombectomy or incision and thrombectomy,can remove or control the primary liver cancer and portal vein tumor thrombus,in order to reduce tumor burden,decrease related complications,and improve liver function.In addition,recent findings suggest that microvascular infiltration is another independent risk factor for early recurrence of single liver cancer without major vascular invasion.However tissue extrusion and tumor disruption during surgery may result in new intrahepatic metastases.The tumor recurrence rate is higher,the tumor-free survival rate is correspondingly lower,and the long-term overall survival after simple hepatectomy is still unsatisfactory.Studies have shown that the tumor tissue receives the dual blood supply of the hepatic artery and the portal vein.The tumor center is supplied by the hepatic artery,peripheral tissue of tumor and the tumor with envelope,the infiltrating cancer tissue and the portal vein tumor thrombus are supplied by the portal vein.When the hepatic artery is embolized,the blood supply of the tumor can be reduced.Then the tumor is chemic necrosis,and the tumor thrombus can be reduced,but the blood supply of the normal liver tissue is not affected.Therefore,hepatic arterial infusion embolization can inactivate residual cancer cells and block the blood supply of new tumor tissues,thus reducing postoperative recurrence,metastasis rate and mortality.The periphery of the tumor is the most active part of tumor growth.Simple hepatic artery perfusion embolization only blocks the hepatic artery blood.Because the hepatic artery is embolized,the portal vein blood is compensated to increase,and the portal vein blood becomes the main blood supply of the tumor through the anastomosis.Therefore,hepatic arterial embolization combining with portal vein perfusion chemotherapy,can not only block the blood supply of liver cancer,but also necrosis of the tumor.It can also kill a small amount of tumor lesions or cancer cells that may remain in the portal vein,and reduce the spread of cancer cells through the portal vein system.Portal vein pump chemotherapy is an important postoperative adjuvant therapy and has unique advantages in preventing recurrence and prolonging postoperative survival.Our previous study found that after radical resection of hepatocellular carcinoma with portal vein chemotherapy,it can effectively reduce the recurrence rate and prolong survival time.The subcutaneous implantable portal vein chemotherapy pump has the characteristics of less trauma,light systemic side reaction,convenient operation and simple nursing.The flushing or chemotherapy can be completed in a community hospital.The patient is well tolerated and has good compliance,which can be a better choice for clinical treatment.Related studies suggest that postoperative transcatheter arterial chemoembolization(TACE)or portal vein chemotherapy(PVC)can reduce postoperative recurrence and metastasis.But the most studies were single-center,small-sample studies.The specific perfusion and embolization regimens are no consensus.This study reviewed the clinical and follow-up data of patients with hepatocellular carcinoma and portal vein tumor thrombus in the hospital and discussed efficacy and safety of hepatic arterial embolization combined with portal vein chemotherapy for hepatocellular carcinoma after hepatectomy,hoping that the results can provide a reference for clinical treatment.Objective1?To clarify the safety of portal vein chemotherapy in the treatment of hepatocellular carcinoma patients.2?To clarify the effect of adjuvant hepatic arterial infusion embolization combined with portal vein chemotherapy in patients of hepatocellular carcinoma with portal vein tumor thrombus after hepatectomy,and to analyze the factors affecting prognosis,so as to provide reference for the development of clinical treatment plan.Methods1?With retrospective case-control study,we collect the clinical data of 1980 patients with hepatocellular carcinoma who underwent treatment from January 2010 to January2016 in the hospital.We selected eighty-four patients with liver cancer who were placed the portal vein chemotherapy pump after hepatectomy as the experimental group(A).Then we selected seventy-five patients who were not placed the portal vein chemotherapy pump during the same period as the control group(B).A total of 159 patients were included in the study.The patients of the experimental group(A)were placed the portal vein chemotherapy pump after hepatectomy and underwent portal vein chemotherapy.The patients of the control group(B)received systemic chemotherapy or other systemic treatments such as sorafenib after hepatectomy.The intraoperative blood loss and perioperative period(postoperative hospital stay,wound healing time)and short-term complications(digestive tract reaction,abdominal hemorrhage,abdominal infection,bile leakage,refractory ascites,liver function failure)were compared between the two groups.We analyzed the long-term complications of patients in the experimental group(A)(extra drug extravasation,catheter blockage,catheter prolapse,wall thrombus),to explore the safety of portal vein chemotherapy through portal vein chemotherapy pump in the treatment of liver cancer.2?With retrospective case-control study,we collect the clinical data of 1980 patients with hepatocellular carcinoma who underwent treatment from January 2010 to January2016 in the hospital.From 84 patients who were placed portal vein chemotherapy pump,we selected 64 patients with portal vein tumor thrombus as the experimental group(C).Then we also delected 55 patients with portal vein tumor thrombus who underwent hepatectomy as the control group(D).A total of 119 patients were included in this study.Experimental group(C):TACE combined with PVC after hepatectomy;control group(D):TACE-assisted treatment after hepatectomy.According to the classification of portal vein tumor thrombus,the experimental group(C)and the control group(D)patients were analyzed hierarchically:30 patients with type I tumor thrombosis were divided into experimental group(E)12 patients and control group(F)18 patients;54 patients with type II tumor thrombus were divided into experimental group(G)35 patients and control group(H)19 patients;35 cases of type III tumor thrombus patients were divided into experimental group(I)17 patients and control group(J)18 patients.Observed indicators:1.the median tumor-free survival and overall survival of the two groups;2.the tumor-free survival rate and overall survival rate of the two groups after half year,1 year,2 years and3 years.The differences between the above indicators and the factors affecting the prognosis of the two groups were compared by univariate and multivariate analysis,and the independent risk factors affecting the prognosis of patients were obtained.Results1?The intraoperative blood loss,postoperative hospital stay and wound healing time of the experimental group(A)and the control group(B)were 810.0±710.9ml vs820.9±630.5ml(t=-0.102,P=0.919),10.7±3.6 days vs 12.0±6.1 days(t=-1.575,P=0.118),13.2±2.6 days vs 15.1±10.2 days(t=-1.664,P=0.098),the difference between the two groups was not statistically significant(P>0.05).2?The short-term complications and adverse reactions in the experimental group(A)and the control group(B)were:7.1%vs 17.3%(?~2=3.911,P=0.048)for digestive tract reaction,1.2%vs 2.7%(?~2=0.010,P=0.921)for abdominal hemorrhage,3.6%vs 2.7%(?~2=0.000,P=1.000)for abdominal infection,4.8%vs 2.7%(?~2=0.076,P=0.783)for bile leakage,9.5%vs 8.0%(?~2=0.115,P=0.735)for refractory ascites,2.4%vs 4.0%(?~2=0.017,P=0.898)for liver function failure.Among them,the incidence of digestive tract reaction in the experimental group(A)was lower than that in the control group(B),and the difference was statistically significant.The incidence of other complications was not statistically significant between the two groups.3?The long-term complication rates of the experimental group(A)were:drug extravasation 3.6%,catheter blockage 4.8%,catheter dislocation 1.2%,subcutaneous infection 1.2%,portal vein wall thrombosis 1.2%.4?The median tumor-free survival of the experimental group(C)and the control group(D)were 13.3 months vs.6.8 months(?~2=8.375,P=0.004).The tumor-free survival rates of half year,1 year,2 years,and 3 years in the experimental group(C)and the control group(D)were 71.9%vs 52.9%(?~2=5.516,P=0.019),57.5%vs 26.7%(?~2=12.232,P=0.000),16.4%vs 8.2%(?~2=7.576,P=0.006),6.9%vs 2.1%(?~2=8.026,P=0.005),the tumor-free survival time of the experimental group(C)and the tumor-free survival rate of half year,1 year,2 years,and 3 years after surgery were better than the control group(D).The difference was statistically significant.5?The median survival time of the experimental group(C)and the control group(D)were 19.5 months vs.12.5 months(?~2=11.690,P=0.001).The survival rates of half year,1year,2 years,and 3 years in the experimental group(C)and the control group(D)were:90.5%vs 89.1%(?~2=0.051,P=0.822),69.5%vs 50.4%(?~2=3.761,P=0.052),39.9%vs 12.1%(?~2=11.807,P=0.001),22.4%vs 8.1%(?~2=10.338,P=0.001),the median survival time and the 2-year and 3-year survival rates of the experimental group(C)were better than the control group(D),the difference was statistically significant,and the difference in survival rate after half year and one year was not statistically significant.6?For 30 patients with type I tumor thrombosis,the median tumor-free survival time of 12 patients in the experimental group(E)and 18 patients in the control group(F)were24.0 months vs 13.5 months(?~2=4.170,P=0.041).The tumor-free survival rates of half year,1 year,2 years,and 3 years in the experimental group(E)and the control group(F)were:91.7%vs 64.9%(?~2=2.584,P=0.108),75.0%vs 51.9%(?~2=1.715,P=0.190),and 50.0%vs 26.0%(?~2=2.347,P=0.126),33.3%vs 6.5%(?~2=3.760,P=0.052),and the median tumor-free survival time of the experimental group(E)was higher than that of the control group(F),and the difference was statistically significant.There were no significant differences in the tumor-free survival rates between the two groups at six months,one year,two years,and three years.The median survival time of the two groups was 40.0 months vs 20.0 months(?~2=7.999,P=0.005).The survival rates of half year,1 year,2 years,and 3years in the experimental group(E)and the control group(F)were:100.0%vs 88.9%(?~2=1.258,P=0.262),90.9%vs 58.7%(?~2=3.552,P=0.059),80.8%vs 26.1%(?~2=7.281,P=0.007),60.6%vs 19.6%(?~2=6.888,P=0.009),the median survival time and the 2-year and 3-year survival rates of the experimental group(E)were better than the control group(F),the difference was statistically significant,and the difference of the survival rate after half year and one year was not statistically significant.7?For 54 patients with type II tumor thrombus,the median tumor-free survival time of 35 patients in the experimental group(G)and 19 patients in the control group(H)were13.6 months vs 6.8 months(?~2=14.630,P=0.000).The tumor-free survival rates of half year,1 year,2 years,and 3 years in the experimental group(G)and the control group(H)were:85.7%vs 52.6%(?~2=8.542,P=0.003),73.9%vs 12.0%(?~2=23.284,P=0.000),12.3%vs0%(?~2=14.630,P=0.000),0%vs0%.The tumor-free survival time and the tumor-free survival rate of the experimental group(G)were better than the control group(H)at half year,1 year and 2 years.The difference was statistically significant.The median survival time of the two groups was 21.7 months vs12.0 months(?~2=7.764,P=0.005).The survival rates after half year,1 year,2 years and 3 years were:100.0%vs 100.0%,85.7%vs 44.6%(?~2=10.322,P=0.001),46.1%vs 11.1%(?~2=10.896,P=0.001),19.7%vs5.6%(?~2=8.745,P=0.003),The survival time and the 1-,2-,and 3-year survival rates in the experimental group(G)were better than the control group(H),and the difference was statistically significant.The survival rate was the same in the first half of the year,both of which were100%.8?For 35 patients with type III tumor thrombus,the median tumor-free survival of the17 patients in the experimental group(I)and the 18 patient in the control group(J)were 5.0months vs.5.9 months(?~2=0.001,P=0.973).The tumor-free survival rates of half year,1year,2 years,and 3 years in the experimental group(I)and the control group(J)were:29.4%vs 41.2%(?~2=0.330,P=0.566),11.8%vs 17.6%(?~2=0.133,P=0.715),0%vs0%,0%vs0%.There was no statistically significant difference in the median tumor-free survival time and the half-year,1-year,2-year,and 3-year tumor-free survival rates between the two groups.The median survival time of the two groups was 6.5 months vs.10.5 months(?~2=0.078,P=0.781).The survival rates of half year,1 year,2 years,and 3 years in the experimental group(I)and the control group(J)were:64.7%vs 77.8%(?~2=0.713,P=0.399),20.2%vs 48.9%(?~2=3.089,P=0.079),0%vs 0%,0%vs 0%.There was no statistically significant difference in the median survival time and half year,1 year,2 years,3 years between the two groups.9?After single factor and multi-factor analysis,the prognostic factors affecting hepatocellular carcinoma with portal vein tumor thrombus were AFP level,tumor size,tumor thrombus classification,postoperative chemotherapy.The patients with AFP?400ng/mL,tumor diameter?10cm,type I and II tumor thrombus,postoperative assisted hepatic arterial infusion and portal vein chemotherapy have a relatively good prognosis.Conclusions1?Placing portal vein chemotherapy pump after hepatectomy is safe,does not increase the risk of surgery,and has fewer postoperative complications.2?For patients of hepatocellular carcinoma with portal vein thrombosis,hepatic arterial infusion embolization combined with portal vein chemotherapy after hepatectomy can reduce the recurrence rate and improve the survival rate.Especially for patients with type I and II tumor thrombus,the effect is better,but for patients with type III tumor thrombus,the effect is relatively poor.3?AFP levels,tumor size,tumor thrombus classification and postoperative treatment are factors influencing the survival prognosis of patients with hepatocellular carcinoma and portal vein tumor thrombus. |
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