Yao Wei,Dong Kuiran,Li Kai,et al.Efficacies of extended hepatic resection for POST-TEXT Ⅲ/Ⅳ hepatoblastoma[J].Journal of Clinical Pediatric Surgery,2020,19(05):386-391.[doi:10.3969/j.issn.1671-6353.2020.05.003]
肝肿瘤切除术治疗POST-TEXT Ⅲ期和Ⅳ期肝母细胞瘤的中长期疗效分析
- Title:
- Efficacies of extended hepatic resection for POST-TEXT Ⅲ/Ⅳ hepatoblastoma
- 关键词:
- 肝肿瘤; POST-TEXT分期; 肝肿瘤切除术; 治疗结果
- 分类号:
- R726.1;R735.7
- 摘要:
- 目的 探讨肝肿瘤切除术治疗POST-TEXT（post-treatment extent of disease）Ⅲ期和Ⅳ期肝母细胞瘤的中长期治疗效果。方法 回顾性分析2009年1月至2019年6月复旦大学附属儿科医院肿瘤外科收治的POST-TEXT Ⅲ期和Ⅳ期肝母细胞瘤患儿的临床资料（包括PRETEXT分期、甲胎蛋白、CT或MRI影像学资料、肿瘤切除术式及预后结果）。采用SPSS18.0统计软件包中的Kaplan-Meier法进行生存分析。结果 本研究共纳入POST-TEXT Ⅲ期和Ⅳ期肝母细胞瘤患儿37例，其中男25例，女12例，发病年龄2~91个月，平均发病年龄（23.92±22.45）个月。POST-TEXTⅢ期和Ⅳ期分别为34例和3例，其中1例PRETEXT Ⅱ期病例治疗过程中升级为POST-TEXT Ⅳ期，3例PRETEXT Ⅳ期病例治疗过程中降级为POST-TEXT Ⅲ期。新辅助化疗2个、4个和6个疗程内手术人数分别为8例（21.6%）、22例（59.4%）和7例（18.9%）。除2例被建议行肝移植手术后放弃治疗外，其余35例均进行肝肿瘤切除术，其中肝三叶切除术7例，扩大半肝切除术8例，不规则肝切除术4例，肝中叶切除术12例，ALPPS（associating liver partition and portal vein ligation for staged hepatectomy）术4例。平均手术时间（262.29±107.16）min，术中平均出血量（236.86±212.41）mL。采用Glisson蒂横断技术22例，平均出血量（147.73±137.46）mL，胆漏发生率27.3%，与未采用该技术的病例比较，出血量明显减少[（147.73±137.46）mL vs.（387.69±235.69）mL，P=0.001]，胆漏发生率相似（27.3%vs. 23.1%，P=0.784）。术中切缘>1 cm者7例（20.0%），切缘0.5~1 cm者15例（42.9%），切缘<0.5 cm者7例（18.9%），紧贴肿瘤边缘切除者6例（16.2%）。随访时间4~124个月，术后肿瘤复发7例，平均复发时间（6±3.96）个月。肿瘤复发率与手术方式及术中切缘距离均无相关性（P>0.05）。5年总体生存率为72.3%，5年无瘤生存率为67.4%。根据切缘距离分类，切缘>1 cm、切缘0.5~1 cm、切缘<0.5 cm及紧贴肿瘤者5年总体生存率分别为85.7%、78.0%、83.3%和53.3%，各组间差异均无统计学意义（P=0.701）。结论 对于POST-TEXT Ⅲ期和Ⅳ期的肝母细胞瘤，根据肿瘤累及的不同部位选择相应的术式，可以取得较好的治疗效果。熟练掌握Glisson鞘分离技术可以减少术中出血和胆道损伤的发生。手术中只需确保一定的切缘距离，就可以减少肿瘤复发，提高远期生存率。
- Abstract:
- Objective To explore the long-term therapeutic outcomes of hepatectomy for POST-TEXT (post-treatment extent of disease) Ⅲ/Ⅳ hepatoblastoma.Methods From January 2009 to June 2019,clinical data were analyzed retrospectively for 37 children of POST-TEXT Ⅲ/Ⅳ hepatoblastoma,including PRETEXT stage,alpha-fetoprotein (AFP),computed tomography (CT) or magnetic imaging imaging (MRI) findings,tumor resection mode and prognostic results.The survival rate was analyzed by Kaplan Meier method of SPSS18.0.Results There were 25 boys and 12 girls with an average age of (23.92±22.45) months.The stages of POST-TEXT were Ⅲ(n=34) and Ⅴ(n=3).One case of PRETEXT Ⅱ was upgraded to POST-TEXT Ⅳ while another three cases of PRETEXT Ⅳ were downgraded to POST-TEXT Ⅲ.Neoadjuvant chemotherapy was performed in 8 cases (21.6%),22 (59.4%) and 7 (18.9%) for 2,4 and 6 cycles respectively.Except for liver transplantation and abandonment of treatment (n=2),the remainders underwent hepatic trisectionectomy (n=7),extended hemihepatectomy (n=8),irregular hepatectomy (n=4),mesohepatectomy (n=12) and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS,n=4).The average operative duration was (262.29±107.16) min and the average bleeding volume (236.86±212.41) ml.The technique of Glisson’s pedicle approach was employed for 22 cases.The average volume of bleeding was (147.73±137.46) ml and the incidence of bile leakage 27.3%.Compared with cases without the technique,the incidence of bleeding was significantly lower (P=0.001) while the incidence of bile leakage was similar (23.1%,P=0.784).Seven cases (20.0%) had a resection margin >1 cm,15 cases (42.9%) a margin of 0.5-1 cm,7 cases (18.9%) a margin <0.5 cm and 6 cases (16.2%) a margin close-to-tumor.The average recurrence time was (6±3.96) months.No significant difference existed between tumor recurrence or operation mode and distance of tumor margin(P>0.05).The overall 5-year survival rate was 72.3% and the 5-year event-free survival rate 67.4%.According to the classification of margin distance,the 5-year overall survival rates of tumor margin >1 cm,0.5-1 cm,<0.5 cm and close-to-tumor were 85.7%,78.0%,83.3% and 53.3% respectively.No significant difference existed among the groups (P=0.701).Conclusion For POST-TEXT Ⅲ/Ⅳ hepatoblastoma,appropriate operations with optimal therapeutic outcomes may be selected according to different parts of tumor involvement.Mastering the technique of Glisson reduces the occurrences of bleeding and bile duct injury.And maintaining a certain margin distance intraoperatively can lower the recurrence of tumor and further improve the survival rate.
参考文献/References:
1 Aronson DC,Meyers RL.Malignant tumors of the liver in children[J].Semin Pediatr Surg,2016,25(5):265-275.DOI:10.1053/j.Sempedsurg.2016.09.002.2.
2 Yoon HM,Hwang J,Kim KW,et al.Prognostic Factors for Event-Free Survival in Pediatric Patients with Hepatoblastoma Based on the 2017 PRETEXT and CHIC-HS Systems[J].Cancers (Basel),2019,11(9):E1387.DOI:10.3390/cancers11091387.
3 Ismail H,Broniszczak D,Kaliciński P,et al.Changing treatment and outcome of children with hepatoblastoma:analysis of a single center experience over the last 20 years[J].J Pediatr Surg,2012,47(7):133-1339.DOI:10.1016/j.jpedsurg.2011.11.073.
4 Lautz TB,Ben-Ami T,Tantemsapya N,et al.Successful nontransplant resection of POSTTEXT Ⅲ and Ⅳ hepatoblastoma[J].Cancer,2011,117(9):197-183.DOI:10.1002/cncr.25722.
5 Fuchs J,Cavdar S,Blumenstock G,et al.POST-TEXT Ⅲ and Ⅳ Hepatoblastoma:Extended Hepatic Resection Avoids Liver Transplantation in Selected Cases[J].Ann Surg,2017,266(2):318-323.DOI:10.1097/SLA.0000000000001936.
6 Perilongo G,Maibach R,Shafford E,et al.Cisplatin versus cisplatin plus doxorubicin for standard-risk hepatoblastoma[J].N Engl J Med,2009,361(17):1662-1670.DOI:10.1056/NEJMoa0810613.
7 Schnater JM,Aronson DC,Plaschkes J,et al.Surgical view of the treatment of patients with hepatoblastoma-Results from the first prospective trial of the International Society of Pediatric Oncology Liver Tumor Study Group (SIOPEL1)[J].Cancer,2002,94(4):1111-1120.DOI:10.1002/cncr.10282.
8 Tajiri T,Kimura O,Fumino S,et al.Surgical strategies for unresectable hepatoblastomas[J].J Pediatr Surg,2012,47(12):2194-2198.DOI:10.1016/j.jpedsurg.2012.09.006.
9 金晟,施诚仁.儿童肝母细胞瘤研究现状[J].临床儿科杂志,2014,32(10):988-992.DOI:10.3969 j.issn.1000-3606.2014.10.023. Jin S,Shi CR.Current research of hepatoblastoma in children[J].J Clin Pediatr,2014,32(10):988-992.DOI:10.3969 j.issn.1000-3606.2014.10.023.
10 Zsíros J,Maibach R,Shafford E,et al.Successful treatment of childhood high-risk hepatoblastoma with dose-intensive multiagent chemotherapy and surgery:final results of the SIOPEL-3HR study[J].J Clin Oncol,2010,28(15):2584-2590.DOI:10.1200/JCO.2009.22.4857.
11 Meyers RL,Tiao G,de Ville de,et al.Hepatoblastoma state of the art:pre-treatment extent of disease,surgical resection guidelines and the role of liver transplantation[J].Curr Opin Pediatr,2014,26(1):29-36.DOI:10.1097/MOP.0000000000000042.
12 Yang T,Whitlock RS,Vasudevan SA.Surgical Management of Hepatoblastoma and Recent Advances[J].Cancers (Basel),2019,11(12):E1944.DOI:10.3390/cancers11121944.
13 El-Gendi A,Fadel S,El-Shafei M,et al.Avoiding liver transplantation in post-treatment extent of disease Ⅲ and Ⅳ hepatoblastoma[J].Pediatr Int,2018,60(9):862-868.DOI:10.1111/ped.13634.
14 Wiederkehr JC,Avilla SG,Mattos E,et al.Associating liver partition with portal vein ligation and staged hepatectomy (ALPPS) for the treatment of liver tumors in children[J].J Pediatr Surg,2015,50(7),1227-1231.DOI:10.1016/j.jpedsurg.2014.10.019.
15 袁妙贤,尹强,刘朝阳.肝脏中叶切除术治疗小儿肝脏肿瘤疗效与安全性分析[J].临床小儿外科杂志,2019,18 (10):859-863.DOI:10.3969/j.issn.1671-6353.2019.10.012. Yuan MX,Yin Q,Liu CY.Experience of mesohepatectomy in the treatment of hepatic tumors in children[J].J Clin Ped Sur,2019,18(10):859-863.DOI:10.3969/j.issn.1671-6353.2019.10.012.
16 Xie KL,Zeng Y,Wu H.Hepatic trisectionectomy for hepatocellular carcinoma using the Glisson pedicle method combined with anterior approach[J].World J Surg,2014,38(9):2358-2362.DOI:10.1007/s00268-014-2579-y.
17 Dicken BJ,Bigam DL,Lees GM.Association between surgical margins and long-term outcome in advanced hepatoblastoma[J].J Pediatr Surg,2004,39(5):721-725.DOI:10.1016/j.jpedsurg.2004.01.035.
相似文献/References:
[1]高会江,董蒨,江布先,等.26例婴儿肝脏肿瘤的临床与病理相关性分析[J].临床小儿外科杂志,2010,9(06):422.
GAO Hui jiang,DONG Qian,JIANG Bu xian,et al.Clinicopathological correlative analysis in infants with liver tumor.[J].Journal of Clinical Pediatric Surgery,2010,9(05):422.
[2]宋非无 李笃妙 吴强. 归脾汤治疗肝母细胞瘤22例疗效观察[J].临床小儿外科杂志,2012,11(05):373.
[J].Journal of Clinical Pediatric Surgery,2012,11(05):373.
[3]乔国梁 李龙 葛军涛. 累及第二、三肝门巨大肝母细胞瘤手术切除41例[J].临床小儿外科杂志,2014,13(02):99.
[4]赵静,董蒨周显军.基于计算机辅助手术系统的儿童肝脏肿瘤与门静脉关系的影像学分析[J].临床小儿外科杂志,2017,16(06):546.
[5]彭宇明 尹 强 高红强 陈立健 袁妙贤.吲哚菁绿荧光染色引导下解剖性右半肝切除治疗儿童肝脏肿瘤[J].临床小儿外科杂志,2018,17(07):0.[doi:10.3969/j.issn.1671-6353.2018. 201805057]
Peng Yumin,Yin Qiang,Gao Hongqiang,et al.Anatomic right-half of indocyanine green fluorescent staining hepatectomy for children with liver tumors.[J].Journal of Clinical Pediatric Surgery,2018,17(05):0.[doi:10.3969/j.issn.1671-6353.2018. 201805057]
[6]彭宇明,尹强,高红强,等.吲哚菁绿荧光染色引导下解剖性右半肝切除治疗儿童肝脏肿瘤[J].临床小儿外科杂志,2018,17(08):597.
Peng Yumin,Yin Qiang,Gao Hongqiang,et al.Anatomic righthalf of indocyanine green fluorescent staining hepatectomy for children with liver tumors.[J].Journal of Clinical Pediatric Surgery,2018,17(05):597.
[7]袁妙贤,尹强,刘朝阳.肝脏中叶切除术治疗小儿肝脏肿瘤的疗效与安全性分析[J].临床小儿外科杂志,2019,18(10):859.[doi:10.3969/j.issn.1671-6353.2019.10.012]
Yuan Miaoxian,Yin Qiang,Liu Chaoyang.Experience of mesohepatectomy in the treatment of hepatic tumors in children[J].Journal of Clinical Pediatric Surgery,2019,18(05):859.[doi:10.3969/j.issn.1671-6353.2019.10.012]
[8]郑百俊,程继文,高亚,等.腹腔镜肝切除术与开腹肝切除术治疗肝母细胞瘤的临床效果比较[J].临床小儿外科杂志,2019,18(11):935.[doi:10.3969/j.issn.1671—6353.2019.11.008]
Zheng Baijun,Cheng Jiwen,Gao Ya,et al.Safety,feasibility and short-term outcome of laparoscopic liver resection versus open liver resection for hepatoblastoma[J].Journal of Clinical Pediatric Surgery,2019,18(05):935.[doi:10.3969/j.issn.1671—6353.2019.11.008]
[9]杨维,任清华,秦红,等.儿童肝母细胞瘤精准肝切除手术效果评价[J].临床小儿外科杂志,2020,19(05):392.[doi:10.3969/j.issn.1671-6353.2020.05.004]
Yang Wei,Ren Qinghua,Qin Hong,et al.Evaluations of precise hepatectomy for pediatric hepatoblastoma[J].Journal of Clinical Pediatric Surgery,2020,19(05):392.[doi:10.3969/j.issn.1671-6353.2020.05.004]
[10]陈芝雪,董瑞.肝母细胞瘤多学科治疗方案的研究进展[J].临床小儿外科杂志,2020,19(05):398.[doi:10.3969/j.issn.1671-6353.2020.05.005]
Chen Zhixue,Dong Rui.Advances in the treatment of hepatoblastoma[J].Journal of Clinical Pediatric Surgery,2020,19(05):398.[doi:10.3969/j.issn.1671-6353.2020.05.005]
备注/Memo
收稿日期:2020-03-08。
基金项目:国家自然科学基金面上项目（编号：81572324）
通讯作者:董岿然,Email:kuirand@hotmail.com