中文English
ISSN 1001-5256 (Print)
ISSN 2097-3497 (Online)
CN 22-1108/R

Efficacy and safety of microsphere transarterid chemoembolization combined with radiotherapy versus microsphere transarterial chemoembolization alone in treatment of patients with unresectable liver cancer

DOI: 10.3969/j.issn.1001-5256.2019.11.020
Research funding:

 

  • Received Date: 2019-06-19
  • Published Date: 2019-11-20
  • Objective To investigate the efficacy and safety of microsphere transarterial chemoembolization( TACE) combined with radiotherapy in the treatment of patients with unresectable liver cancer. Methods A total of 68 patients with unresectable liver cancer were enrolled in Shantou central hospital from January 2016 to October 2018,among whom there were 65 male and 3 female patients,with a median age of 55 years( range 36-75 years). These patients were randomly divided into microsphere TACE group with 34 patients and microsphere TACE combined with radiotherapy group( combined group with 34 patients). The two groups were compared in terms of short-term response rate,progression-free survival( PFS) rate,overall survival( OS) rate,and adverse events to evaluate safety. The chi-square test was used for comparison of categorical data between groups,and the Kaplan-Meier method and the log-rank test were used for comparison of PFS and OS rates. Results Up to the last follow-up on April 30,2019,all patients completed treatment as planned and the median follow-up time was 15. 2 months. A total of 25 deaths were observed. The objective response rate was 50. 0% in the microsphere TACE group and 76. 5% in the combined group,and the combined group had a significantly better short-term response than the microsphere TACE group( χ2= 7. 995,P = 0. 046). For the microsphere TACE group,the 6-,12-,18-,and 24-month OS and PFS rates were 94. 1%/76. 5%,69. 0%/47. 1%,51. 3%/23. 9%,and 30. 9%/9. 6%,respectively,and for the combined group,the 6-,12-,18-,and 24-month OS and PFS rates were 100%/93. 7%,87. 8%/81. 1%,75. 1%/52. 9%,and 58. 2%/44. 1%,respectively; the combined group had significantly better PFS and OS time than the microsphere TACE group( χ2= 9. 027 and 4. 288,P = 0. 002 7 and 0. 038). There was a low incidence rate of adverse events in the two groups,and no treatment-related death was observed. Conclusion Compared with microsphere TACE alone,microsphere TACE combined with radiotherapy significantly improves short-term response and long-term survival in patients with unresectable liver cancer and thus provides a more effective and safer treatment for such patients.

     

  • 随着经济水平的发展和膳食结构的改变,我国2型糖尿病(T2DM)的患病率一直处于上升趋势,流行病学调查显示我国18岁及以上成年人中T2DM的患病率已达11.2%[1]。非酒精性脂肪性肝病(NAFLD)是肝细胞内脂质的过度沉积[2],T2DM与NAFLD的关系已得到充分认可。T2DM合并NAFLD的全球患病率为55.5%[3],对于T2DM合并NAFLD的预测具有重要的意义。肥胖和胰岛素抵抗(IR)是T2DM合并NAFLD的危险因素[4]。BMI是判断肥胖的常用指标,甘油三酯葡萄糖乘积指数(triglyceride-glucose index,TyG)可反应体内的IR。因此,本研究通过回顾性分析中国医科大学附属盛京医院T2DM合并NAFLD患者的临床资料,探讨TyG联合BMI对T2DM合并NAFLD的预测价值。

    收集2020年5月—2021年7月经本院诊治为T2DM患者的临床资料,T2DM的诊断符合《中国2型糖尿病防治指南(2020年版)》[5],按照有无NAFLD分为T2DM合并NAFLD组和单纯T2DM组,NAFLD的诊断符合《非酒精性脂肪性肝病防治指南(2018更新版)》[6]

    排除标准:(1)年龄<18岁或>65岁的患者;(2)1型糖尿病及其他类型糖尿病患者,2型糖尿病并发酮症酸中毒或高渗昏迷等急性并发症的患者;(3)酒精性肝病、病毒性肝炎、药物性肝损伤、自身免疫性肝病、遗传代谢性肝病等其他肝病患者;(4)恶性肿瘤患者;(5)近3个月口服保肝药物的患者。

    1.2.1   一般资料测量

    (1) 测量患者的身高和晨起体质量,计算BMI;(2)测量晨起静息状态下右上臂收缩压及舒张压。

    1.2.2   生化指标检测

    清晨空腹采肘静脉血,采用日立7600全自动生化分析仪检测AST、ALT、GGT、TBil、IBil、DBil、TG、TC、HDL-C、LDL-C、空腹血糖(FBG)、糖化血红蛋白(HbA1c)。计算TyG指数,TyG=ln[TG(mg/dL)× FBG(mg/dL)/2]。

    1.2.3   肝脏彩超检测

    使用TOSHIBA Aplio500彩色多普勒超声于空腹状态下检查肝脏,NAFLD表现包括肝脏近场回声增强、肝内管道结构显示不清、远场回声衰减等特征。

    采用SPSS 25.0统计学软件进行分析。符合正态分布的计量资料以x±s表示,两组间比较采用独立样本t检验;不符合正态分布的计量资料以M(P25~P75)表示,两组间比较采用Mann-Whitney U检验;计数资料两组间比较采用χ2检验。采用logistic回归分析TyG及BMI与T2DM合并NAFLD的关系;绘制受试者工作特征曲线(ROC曲线)评价TyG、BMI及TyG联合BMI对T2DM合并NAFLD的预测效能,测量曲线下面积(AUC),根据约登指数最大原则确定最佳截断点,并计算敏感度、特异度、阳性预测值、阴性预测值,采用Kappa系数分析预测结果的一致性程度。P<0.05为差异有统计学意义。

    共纳入T2DM患者349例。T2DM合并NAFLD组213例,其中男139例,女74例,年龄21~65岁,平均(45.59±12.53) 岁;单纯T2DM组136例,其中男95例,女41例,年龄19~64岁,平均(43.82±12.95)岁。两组的年龄(t=1.265)、性别(χ2=0.793)差异均无统计学意义(P值均>0.05)。

    T2DM合并NAFLD组的BMI、舒张压、FBG、HbA1c、ALT、AST、GGT、TG、TC、LDL-C、TyG均高于单纯T2DM组(P值均<0.05),T2DM合并NAFLD组的HDL-C低于单纯T2DM组(P<0.05),两组在收缩压、TBil、DBil、IBil间的差异均无统计学意义(P值均>0.05)(表 1)。

    表  1  两组一般资料的比较
    Table  1.  Comparison of general data between two groups
    指标 T2DM合并NAFLD组(n=213) 单纯T2DM组(n=136) 统计值 P
    BMI(kg/m2) 26.33(24.52~29.37) 23.23(21.92~25.39) Z=-9.044 <0.001
    收缩压(mmHg) 130.00(120.00~140.00) 130.00(120.00~140.00) Z=-1.729 0.084
    舒张压(mmHg) 80.00(80.00~90.00) 80.00(75.00~84.00) Z=-3.251 0.001
    FBG(mmol/L) 9.85(8.20~12.29) 7.96(6.36~9.68) Z=-6.126 <0.001
    HbA1c(%) 8.90(7.45~10.25) 7.35(6.50~9.05) Z=-5.075 <0.001
    ALT(U/L) 31.00(22.00~44.00) 21.00(13.00~26.00) Z=-7.820 <0.001
    AST(U/L) 22.00(17.00~29.00) 18.00(15.00~21.00) Z=-5.447 <0.001
    GGT(U/L) 36.00(24.00~56.00) 18.00(13.00~25.25) Z=-9.402 <0.001
    TBil(μmol/L) 10.25(8.30~13.40) 10.40(7.80~13.20) Z=-0.098 0.922
    DBil(μmol/L) 3.20(2.50~4.18) 3.30(2.53~4.38) Z=-1.129 0.259
    IBil(μmol/L) 7.25(5.40~9.20) 7.05(5.25~9.00) Z=-0.226 0.821
    TG(mmol/L) 2.42(1.74~3.63) 1.07(0.81~1.50) Z=-11.831 <0.001
    TC(mmol/L) 5.04(4.28~5.96) 4.21(3.86~4.70) Z=-7.188 <0.001
    HDL-C(mmol/L) 1.02(0.88~1.25) 1.16(1.02~1.37) Z=-4.897 <0.001
    LDL-C(mmol/L) 3.28(2.63~3.97) 2.87(2.63~3.87) Z=-4.042 <0.001
    TyG 9.98±0.79 8.87±0.61 t=13.832 <0.001
    下载: 导出CSV 
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    以是否合并NAFLD为因变量,TyG和BMI为自变量纳入logistic回归方程,提示TyG和BMI为T2DM合并NAFLD的危险因素。校正单因素分析具有统计学差异的舒张压、FBG、HbA1c、ALT、AST、GGT、TG、TC、LDL-C、HDL-C后,仍具有统计学意义,表示TyG和BMI均为T2DM合并NAFLD的独立危险因素(表 2)。

    表  2  TyG、BMI与T2DM合并NAFLD的logistic回归分析
    Table  2.  Logistic regression analysis of TyG, BMI in T2DM combined with NAFLD
    指标 β 标准误 Wald值 OR 95%CI P
    校正前BMI 0.392 0.051 59.377 1.479 1.339~1.634 <0.001
    校正前TyG 2.439 0.269 82.237 11.459 6.764~19.411 <0.001
    校正后BMI 0.314 0.071 19.390 1.369 1.191~1.575 <0.001
    校正后TyG 1.874 0.633 8.766 6.513 1.884~22.517 0.003
    下载: 导出CSV 
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    根据ROC曲线结果可见,TyG和BMI预测T2DM合并NAFLD的最佳截断点分别为9.41、24.22,TyG预测的AUC、特异度、敏感度、阳性预测值、阴性预测值均高于BMI,二者联合可以进一步提高预测效能。Kappa系数显示TyG联合BMI预测T2DM合并NAFLD具有更好的一致性(图 1表 3)。

    图  1  TyG、BMI及TyG联合BMI预测T2DM合并NAFLD的ROC曲线
    Figure  1.  ROC curve of TyG, BMI and TyG combined with BMI for predicting T2DM combined with NAFLD
    表  3  TyG、BMI及TyG联合BMI对T2DM合并NAFLD的预测价值
    Table  3.  Predictive value of TyG, BMI and TyG combined BMI for T2DM combined with NAFLD
    指标 最佳截断点 AUC 95%CI 敏感度(%) 特异度(%) 阳性预测值(%) 阴性预测值(%) Kappa系数
    BMI 24.22 0.787 0.740~0.834 78.9 64.0 77.36 64.23 0.416
    TyG 9.41 0.875 0.839~0.911 80.3 80.1 86.36 72.19 0.592
    TyG联合BMI 0.910 0.881~0.940 81.2 88.2 91.53 75.00 0.673
    下载: 导出CSV 
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    超声作为最常用的影像学检查方法,广泛用于临床上对于脂肪肝的诊断,但超声对于轻度脂肪肝的检出率及敏感性较低[7],且超声在诊断脂肪肝过程中易受操作者主观判断及患者皮下脂肪厚度、脾肾回声、肝纤维化的影响,使其有一定的局限性[8]。因此,寻找一个简单可行的,不受操作者主观影响的无创指标,对于NAFLD的预测具有重要的临床意义。BMI包含身高和体质量,TyG包含TG和FBG,均为日常工作中最基础的指标,构成简单,应用方便,因此具有用于预测T2DM合并NAFLD的基本要求。

    BMI升高反映着超重和肥胖的存在,本研究结果显示BMI是T2DM合并NAFLD的独立危险因素,原因在于:(1)超重或肥胖时出现脂肪营养不良,肝细胞则会储存多余的脂质[9];(2)脂肪细胞肥大、增生的过程中产生细胞因子,释放脂肪酸,在肝脏内积聚后诱发肝脏炎症反应、细胞损伤及凋亡[10];(3)肥胖时分泌的脂肪因子向更具脂肪及纤维生成性、炎症性的方向转移[11],加重肝损伤。超重或肥胖与NAFLD有着密切的关系,因此BMI可用于预测T2DM合并NAFLD的发生。

    IR是T2DM和NAFLD的发病基础。TyG指数最早由Simental-Mendía于2008年提出[12],与评估IR金标准的高胰岛素-正葡萄糖钳夹试验显著相关[13],因此也被看作是IR的标志物[14]。IR在T2DM合并NAFLD中的影响在于:(1)IR时外周组织对胰岛素的敏感性下降,胰岛素对脂解的抑制作用也减弱,导致游离脂肪酸异位沉积于肝脏中[15-16]。(2)IR状态下的高胰岛素和高血糖上调SREBP1c和ChEBP活性,激活糖分解和脂肪生成酶,刺激肝脏脂肪的从头合成[17]。(3)IR活化巨噬细胞,介导肝巨噬细胞和肝星状细胞关联,促进NAFLD发展为肝纤维化甚至肝癌[18]。因此,作为IR标志物的TyG可预测T2DM中的NAFLD。

    本研究结果指出TyG联合BMI对T2DM合并NAFLD的预测效能和一致性水平上高于单一指标检测,考虑在于二者联合综合了IR和肥胖对T2DM合并NAFLD的影响,所以提高了预测价值。目前对于NAFLD的筛查要求,也指出在明确NAFLD的同时应评估患者是否同时存在其他代谢综合征组分[19],所以,TyG联合BMI在预测NAFLD的同时,也能对肥胖、IR、血糖血脂等代谢组分的评估进行指导,因此具有较高的应用价值。

    综上所述,应重视T2DM合并NAFLD的预测,TyG和BMI可作为预测T2DM合并NAFLD的指标,联合用于T2DM合并NAFLD的筛查与管理。

  • [1] TORRE LA,BRAY F,SIEGEL RL,et al. Global cancer statistics,2012[J]. CA Cancer J Clin,2015,65(2):87-108.
    [2] Chinese Expert Consensus Statement Chinese Society of Liver Cancer(CSLC), Chinese Society of Clinical Oncology(CSCO),Liver Cancer Group,Chinese Society of Hepatology.Consensus on standardized diagnosis and treatment of primary liver cancer[J]. J Clin Hepatol,2009,25(2):83-92.(in Chinese)中国抗癌协会肝癌专业委员会,中国抗癌协会临床肿瘤学协作专业委员会,中华医学会肝病学分会肝癌学组.原发性肝癌规范化诊治的专家共识[J].临床肝胆病杂志,2009,25(2):83-92.
    [3] BETTINGER D,GKIKA E,SCHULTHEISS M,et al. Comparison of local tumor control in patients with HCC treated with SBRT or TACE:A propensity score analysis[J]. BMC Cancer,2018,18(1):807.
    [4] WANG H,PAN YG,XIA JT,et al. Clinical effect of transcatheter arterial chemoembolization in treatment of primary liver cancer:Application and research advances[J]. J Clin Hepatol,2018,34(2):414-418.(in Chinese)王辉,潘裕国,夏金堂,等.经肝动脉化疗栓塞术在原发性肝癌治疗中的应用[J].临床肝胆病杂志,2018,34(2):414-418.
    [5] CHIANG CL,CHAN MKH,YEUNG CSY,et al. Combined stereotactic body radiotherapy and trans-arterial chemoembolization as initial treatment in BCLC stage B-C hepatocellular carcinoma[J]. Strahlenther Onkol,2019,195(3):254-264.
    [6] WANG HY. Clinical effect of Embosphere microsphere in transarterial chemoembolization for liver cancer[D]. Qingdao:Qingdao University,2017.(in Chinese)王洪雨.Embosphere微球在肝癌TACE治疗中的临床疗效分析[D].青岛:青岛大学,2017.
    [7] WU BL,ZHOU J,LING GH,et al. Efficacy and safety analysis of 8Spheres microspheres combined with lipiodol TACE in the treatment of hepatocellular carcinoma[J]. Med J Wuhan Univ,2018,39(2):248-252.(in Chinese)吴宝林,周军,凌公豪,等.8Spheres微球联合碘油TACE治疗原发性肝癌的疗效及安全性[J].武汉大学学报:医学版,2018,39(2):248-252.
    [8] National Health and Family Planning Commission of the People's Republic of China. Diagnosis,management,and treatment of hepatocellular carcinoma(V2017)[J]. J Clin Hepatol,2017,33(8):1419-1431.(in Chinese)中华人民共和国国家卫生和计划生育委员会.原发性肝癌诊疗规范(2017年版)[J].临床肝胆病杂志,2017,33(8):1419-1431.
    [9] Chinese College of Interventionalists,Chinese Med. Chinese Clinical Practice Guidelines for transarterial chemoembolization of hepatocellular carcinoma[J]. Chin J Radiol,2019,54(3):246-255.(in Chinese)中国医师协会介入医师分会.中国肝细胞癌经动脉化疗栓塞治疗(TACE)临床实践指南[J].中华放射学杂志,2019,54(3):246-255.
    [10] SEYAL AR,GONZALEZ-GUINDALINI FD,ARSLANOGLU A,et al. Reproducibility of m RECIST in assessing response to transarterial radioembolization therapy in hepatocellular carcinoma[J]. Hepatology,2015,62(4):1111-1121.
    [11] CHEN LC,CHIOU WY,LIN HY,et al. Comparing stereotactic ablative radiotherapy(SABR)versus re-trans-catheter arterial chemoembolization(re-TACE)for hepatocellular carcinoma patients who had incomplete response after initial TACE(TASABR):A randomized controlled trial[J]. BMC Cancer,2019,19(1):275.
    [12] LIU LB,WANG JF,CHENG GH,et al. Explanation of diagnostic criteria for radiation-induced liver diseases[J]. Int J Radiat Med Nuclear Med,2012,36(4):252-255.(in Chinese)刘丽波,王剑峰,程光惠,等.《放射性肝病诊断标准》解读[J].国际放射医学核医学杂志,2012,36(4):252-255.
    [13] LI SY,WU S,CHEN TS,et al. Effect of portal venous perfusion cinobufacini injection combined with TACE in patients with intermediate hepatocellular carcinoma[J]. Clin J Med Offic,2017,45(9):884-886.(in Chinese)李淑英,吴申,陈挺松,等.经导管肝动脉栓塞化疗联合华蟾素门静脉灌注治疗中期原发性肝癌疗效研究[J].临床军医杂志,2017,45(9):884-846.
    [14] KOTHARY N,WEINTRAUB JL,SUSMAN J,et al. Transarterial chemoembolization for primary hepatocellular carcinoma in patients at high risk[J]. J Vasc Interv Radiol,2007,18(12):1517-1526; quiz 1527.
    [15] ZHU LL,CAI CF,MENG Y. Therapeutic efficiency of transcatheter arterial chemoembolization combined with intensity modulated radiation therapy against un-resectable primary hepatocellular carcinoma[J]. Int J Med Radiol,2019,42(2):149-153.(in Chinese)朱六玲,蔡陈枫,孟岩.TACE联合调强放疗对不可切除原发性肝癌的疗效研究[J].国际医学放射学杂志,2019,42(2):149-153.
    [16] MA M,NIU TT,SHAO L,et al. Hepatic transcatheter arterial chemoembolization combined with stereotactic radia-tion therapy of primary liver cancer[J]. Trauma and Crit Medicine,2017,5(1):32-35.(in Chinese)马明,牛婷婷,邵亮,等.肝动脉化疗栓塞术联合立体定向放疗治疗较大原发性肝癌临床研究[J].创伤与急危重病医学,2017,5(1):32-35.
    [17] LENG ZQ,LIANG ZY,SHI S. Clinical effect of interventional treatment,radiotherapy,and multimodality therapy for liver cancer[J]. Chin J Radiat Oncol,2000,9(2):99.(in Chinese)冷祝强,梁赵玉,石珊.肝癌介入治疗放射治疗及综合治疗的疗效分析[J].中华放射肿瘤学杂志,2000,9(2):99.
    [18] SEONG J,PARK HC,HAN KH,et al. Clinical results and prognostic factors in radiotherapy for unresectable hepatocellular carcinoma:A retrospective study of 158 patients[J]. Int J Radiat Oncol Biol Phys,2003,55(2):329-336.
    [19] ZHANG YW,ZHANG Y,LING ZH,et al. Clinical effect of threedimensional conformal radiotherapy combined with transarterial chemoembolization versus transarterial chemoembolization alone in treatment of liver cancer:A meta-analysis[J]. J South Med Univ,2009,29(12):2514-2516.(in Chinese)张耀伟,张勇,凌志海,等.三维适形放疗联合TACE与单纯TACE治疗肝癌疗效的meta分析[J].南方医科大学学报,2009,29(12):2514-2516.
    [20] LUO JJ,YAN ZP,WANG JH,et al. HCC embolized by microspheres and iodized oil compared with by iodized oil alone[J]. Chin Comput Med Imag,2008,14(2):154-159.(in Chinese)罗剑钧,颜志平,王建华,等.微球+碘化油联合栓塞与碘化油单独栓塞治疗肝癌的比较研究[J].中国医学计算机成像杂志,2008,14(2):154-159.
    [21] ZHANG JX,LI FZ,CHAI J,et al. Clinical and controlled trial of transcatheter arterial chemoembolization with polyvinyl alcohol particle in patients with advanced hepatocellular carcinoma[J]. J Hepatopancreatobiliary Surg,2014,26(3):195-197,203.(in Chinese)张军喜,李发中,柴健,等.微球加碘化油栓塞治疗肝癌疗效的临床对照研究[J].肝胆胰外科杂志,2014,26(3):195-197,203.
    [22] XU YZ,DING YM,YANG Y. Combining chemoembolization using microspheres with iodized oil in the treatment of hepatocellular carcinoma:A Meta-analysis of randomized controlled trials[J]. Chin J Hepatobiliary Surg,2014,20(1):24-28.(in Chinese)徐彦哲,丁佑铭,杨阳.微球联合碘化油栓塞化疗治疗肝细胞癌的Meta分析[J].中华肝胆外科杂志,2014,20(1):24-28.
    [23] CAO G,WEN F. Comparison of microspheres embolization with lipiodol embolization[J]. Chin J Interv Imaging Ther,2016,13(8):518-519.(in Chinese)曹广,温峰.微球栓塞与碘油栓塞的比较[J].中国介入影像与治疗学,2016,13(8):518-519.
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