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目的评价肝细胞肝癌腹腔淋巴结转移病人接受与不接受放射治疗的效果,并分析影响患者的预后因素。方法回顾125例临床诊断为肝细胞肝癌腹腔淋巴结转移病人,分为非放疗组和放疗组。非放疗组患者出现腹腔淋巴结转移后,仅针对肝内肿瘤予手术切除或介入栓塞治疗;放疗组病人在原有治疗的基础上结合外放射治疗,用直线加速器发射的15MV光子,予肿大淋巴结区包括或不包括肝内原发灶局部照射,常规分割,放疗剂量为40～60Gy。分析两组患者的临床指标,甲胎蛋白(AFP)、肝内肿瘤大小、肝内肿瘤治疗的方法、淋巴结情况(位置、数目、大小)、是否伴有癌栓、Child-Pugh肝功能分级。生存率的估计用Kaplan-Meier法,Cox回归分析各因素对预后的影响。结果62例腹腔淋巴结转移患者接受放疗,23例(37.1%)放疗后转移的淋巴结消失,归为完全缓解,37例(59.7%)为部分缓解,客观缓解率达96.8%。放疗后淋巴结压迫出现的症状得到缓解,有效率100%。放疗组与非放疗组中位生存期分别为9.4个月和3.3个月,1年生存率分别为42.1%和3.4%,2年生存率分别为19.9%和0%。两组间差别有显著意义(P<0.001)。放疗组患者出现肝门、胰周、腹主动脉旁淋巴结转移者,其中位生存期分别为24.1个月、9.4个月、6.0个月,对照组分别为3.6个月、3.8个月、3.2个月。放疗组肝内肿瘤直径<8cm或≥8cm者,中位生存期分别为12.3个月和5.7个月,非放疗组分别为3.3个月和3.6个月。用Cox回归模型进行单因素与多因素分析生存情况,生存情况与下列因素有明显相关,Child-Pugh肝功能分级高、伴有癌栓、肝内多发病灶、原发灶未治疗者预后差。非放射治疗的病人,43.5%(2762)患者死于淋巴结肿大相关的并发症。外放疗可以降低淋巴结引起死亡(淋巴结致死降至8.0%),但胃肠道出血发生率上升。放射治疗主要不良反应为中等程度的急性胃肠道反应和肝损伤,常表现为食欲下降和恶心。结论本文结果提示,肝细胞肝癌淋巴结转移对放疗敏感。用50Gy的常规分割即可起到姑息治疗的效果,并延长生存期。肝门区淋巴结转移和肝内小病灶的患者放疗后效果较好。
Objective To evaluate the effect of radiotherapy on patients with hepatocellular carcinoma with or without peritoneal lymph node metastasis and to analyze the prognostic factors affecting the patients. Methods 125 cases of hepatocellular carcinoma with celiac lymph node metastasis were retrospectively analyzed. They were divided into non-radiotherapy group and radiotherapy group. Non-radiotherapy group patients with abdominal lymph node metastasis, only for intrahepatic tumors were treated with surgical resection or interventional embolization; radiotherapy group patients on the basis of the original treatment combined with external radiation therapy, with a linear accelerator emitted 15MV photons to the enlarged lymph node area Including or not including local intrahepatic local irradiation, conventional segmentation, radiotherapy dose of 40 ~ 60Gy. The clinical parameters, AFP, intrahepatic tumor size, intrahepatic tumor treatment, lymph node status (location, number, size), tumor thrombus and Child-Pugh liver function classification were analyzed. The survival rate was estimated by Kaplan-Meier method, Cox regression analysis of the impact of various factors on the prognosis. Results 62 cases of patients with celiac lymph node metastasis underwent radiotherapy. The lymph node metastasis disappeared after radiotherapy in 23 cases (37.1%) and was completely relieved. 37 cases (59.7%) were partially relieved and the objective response rate was 96.8%. Lymphatic pressure after radiotherapy symptoms have been alleviated, with an efficiency of 100%. Median survival was 9.4 months and 3.3 months for radiotherapy versus non-radiotherapy, respectively, with 1-year survival rates of 42.1% and 3.4%, respectively, and 2-year survival rates of 19.9% and 0%, respectively. The difference between the two groups was significant (P <0.001). Patients in the radiotherapy group had hepatic hilar, peripancreatic and para-aortic lymph node metastases with median survival of 24.1 months, 9.4 months and 6.0 months, respectively, while those in the control group were 3.6 months, 3.8 months and 3.2 months month. Radiotherapy group intrahepatic tumor diameter <8cm or ≥ 8cm, the median survival was 12.3 months and 5.7 months, non-radiation group were 3.3 months and 3.6 months. Univariate and multivariate analysis of survival, survival and the following factors were significantly associated with Cox regression model. Child-Pugh liver function was high grade, with thrombus, multiple intrahepatic lesions, poor prognosis of the primary tumor without treatment. Non-radiation therapy patients, 43.5% (2762) patients died of complications related to lymph node enlargement. External radiotherapy can reduce lymph node death (lymph node death decreased to 8.0%), but the incidence of gastrointestinal bleeding increased. The main adverse effects of radiation therapy for the moderate degree of acute gastrointestinal reactions and liver damage, often manifested as decreased appetite and nausea. Conclusions The results of this study suggest that lymph node metastasis of hepatocellular carcinoma is sensitive to radiotherapy. With 50Gy conventional partition can play palliative effect and prolong survival. Hilar lymph node metastasis and intrahepatic small lesions in patients with better results after radiotherapy.