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.
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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