Three Dimensional Conformal Radiation Therapy to Portal Vein Thrombosis Area as the Initial Treatment for Hepatocellular Carcinoma With Portal Vein Thrombosis: Prognostic Factors and Outcome for Patie

以三度空間順形放射治療門靜脈栓塞為肝癌合併門靜脈栓塞之初始治療方法：對於無法接受其他治療但完成放射治療病人之預後因子與結果

黃郁傑(Yu-Jie Huang) ； 梁雲(Stephen Wan Leung) ； 王重榮(Chong-Jong Wang) ； 孫立民(Li-Min Sun) ； 葉世安(Shyh-An Yeh) ； 黃英彥(Eng-Yen Huang) ； 陳惠君(Hui-Chun Chen) ； 方富民(Fu-Min Fang) ； 熊敬業(Ching-Yeh Hsiung) ； 許軒之(Hsuan-Chih Hsu)

《放射治療與腫瘤學》 8卷1期 (2001/03) Pp. 1-14

https://doi.org/10.6316/TRO/200108(1)1

摘要

研究背景及目的：肝癌合併門靜脈栓塞之預後不佳，並且是做經皮肝動脈血管栓塞治療（TAE）的禁忌症。雖然過去已經證實傳統的肝癌放射治療方法效果不彰，三度空間順形放射治療卻可能是另一個可選擇的替代方案。在這個研究當中，我們將分析以三度空間順形放射治療治療門靜脈栓塞為肝癌合併門靜脈栓塞為初始療法之預後因子與結果。
材料與方法：從1997年九月到1999年八月，共有42位病人被轉介至本科其初始診斷為肝癌合併門靜脈栓塞並且沒有接受過任何治療以及西方癌病聯合組織（ECOG）功能狀態優於二級，這些病人即為我們研究的對象。他們依照個人不同的情形針對門靜脈栓塞區域以三度空間順形放射治療給予50到61.3格雷的劑量，每日分次劑量為1.8至2.5格雷。年齡、性別、ECOG功能狀態、Child-Pugh分級、腫瘤位置、腫瘤型態、門靜脈栓塞位置、放射治療照射體積、甲型胎兒蛋白、上消化道出血病史、B型及C型肝炎標記以及接受放射治療前、治療中、治療後的肝功能指數，包括了麩草醋酸氨基轉移?（AST）、氨基丙酸轉氫?（ALT）及總黃疸指數（Bil-T），皆被紀錄下來以供分析。
結果：共有24位（57%）病患完成了放射治療療程，其他則是因為ECOG功能狀態惡化停止治療，其中有7個病人在治療後失去追蹤。在追蹤的17位病患當中有9位（53%）對放射治療有反應，其中又有7位（41%）病患在治療後可繼續接受TAE治療。完成放射治療療程的病患其3個月及6個月存活率為63%及34%。而未完成放射治療療程的病患則為24%及8%。在完成及未完成放射治療療程的病人之間，其存活率有明顯統計上的差異（p= 0.022）。病患治療前、中、後的AST，ALT及Bil-T無明顯統計上的差異，只有6位病患（35%）有疑似胃部併發症之報告。Bil-T是在統計學上唯一對預測病患可否完成放射治療有意義之因子（p = 0.028）。
結論：此研究的病患選擇與預後不佳，只有少於一半的病人可以完成放射治療與完整的病程追蹤。因此，進一步前膽性控制且選擇病患良好的研究是必須的，例如選擇低Bil-T之病人，來評估此種治療的可行性，治療失敗復發的型態，以及採用三度空間順形放射治療作為肝癌合併門靜脈栓塞之初始療法的真正效益。

關鍵字

肝癌 ； 門靜脈栓塞 ； 三度空間順形放射治療

並列摘要

Background and Purpose: Hepatocellular carcinoma (HCC) with portal vein thrombosis (PVT) indicated poor prognosis and is the contraindication for transcatheter hepatic arterial embolization (TAE). Although the conventional method of external irradiation to HCC has been proven not effective, three-dimensional conformal radiation therapy (3D-CRT) may be an alternative choice. In this study, the prognostic factors and results of 3D-CRT to PVT area as the initial treatment for HCC with PVT patients who could not receive other treatments was investigated.
Materials and Methods : From September 1997 to August 1999, 42 patients who were initially diagnosed as HCC with PVT without any previous treatment and Eastern Cooperative Oncology Group (ECOG) performance status superior to Grade II were enrolled into the study. Radiation therapy (RT) was given via 3D-CRT technique to PVT area with 50 Gy to 61.3 Gy in daily fraction of 1.8 Gy to 2.5 Gy by individual condition. Age, sex, ECOG performance status, Child-Pugh classification, tumor location, tumor type, invaded PVT area, radiation treatment volume, alpha-fetoprotein (AFP), upper gastrointestinal (UGI) bleeding history, viral hepatitis markers for B and C, and pre-treatment liver function, on-treatment liver function, post-treatment liver function, including Aspartate Aminotransferase (AST), Alanine Aminotransferase (ALT) and Total Bilirubin (Bil-T), were recorded for analysis.
Results: Twenty-four patients (57%) completed the RT course and others withdrew from RT due to worsened ECOG performance status. Seven complete RT patients were lost to follow-up. Nine of 17 followed patients (53%) had positive response to RT. Seven patients (41%) underwent further TAE after RT. In the patients who could complete RT, overall survival for 3 months and 6 months were 63% and 34%. Survival rate for incomplete RT patients was 24% and 8% for 3 months and 6 months respectively. There was statistically significant difference (p = 0.022) in survival between patients who completed RT and their counterpart. There were no significant difference in pre-treatment, on-treatment and post-treatment AST, ALT and Bil-T level. Only 6 patients (35%) were reported to have suspicious gastric complications. Bil-T was the only significant factor for predicting whether RT could be completed or not (p = 0.028).
Conclusions : Less than half of the patients completed the planned RT and were adequately followed, indicating the poor prognosis and selection of patients in this study. Further prospective control studies with appropriate patient enrollment, such as low bilirubin level, is required to verify the feasibility, patterns of failure, and the possible benefit of 3D-CRT as the initial treatment of HCC with PVT.

並列關鍵字

Hepatocellular carcinoma ； Portal vein thrombosis ； Three-dimensional conformal radiotherapy