經肝動脈化療栓塞治療 (Transcatheter Arterial Chemoembolization)是肝癌中期患者的標準治療，它被認為是當病人符合下列臨床狀況:（1）合理肝功能；（2）大（> 5cm）或多顆腫瘤不阻塞門靜脈血管，（3）和沒有肝外擴散時的標準治療選擇。正如我們所知，肝門靜脈栓塞（PVTT）如果不及時治療平均僅有3個月存活的時間，此議題是重要存活預後因素。體外放射治療法（EBRT）是針對肝門靜脈栓塞給予更精準的治療、更高的劑量，安全治療控制肝腫瘤及減少正常肝臟組織的傷害，而不引起嚴重的併發症，因此本研究目的欲探討體外放射線療法合併經肝動脈化療栓塞對於治療門靜脈栓塞與肝臟腫瘤同時共存發生時，其治療成效與末期肝癌病人存活預後相關臨床因素分析。本世代研究採用病歷回溯方式，從2006年3月至2014年 12月，收集中部某醫學中心255位晚期肝癌患者 (BCLC stage C)，將1)無治療前後放射影像，2) 無後續治療追蹤者排除，最後納入96位接受體外放射治療法與經肝動脈化療栓塞合併治療對於此病人存活情形進行研究分析，本研究中病人累積發生率(accumulative rate) 與存活率(survival cure) 採用Kaplan-Meier 分析，而治療所造成病人死亡的風險，以Cox比例風險回歸分析 (Cox proportional hazard regression model )來計算危險比值(Hazard ratio)。本硏究共納入96位患者，平均整體存活為14.8±0.9個月，其中慢性B型肝炎是最常見的肝癌危險因素佔41%，經肝動脈化療栓塞治療次數(HR:0.85; 95% 信賴區間:0.75-0.96)，肝癌腫瘤大小 (HR:1.15; 95% 信賴區間:1.02-1.17 )，治療後有達到病變不惡化 (disease stabilization) (HR:0.15; 95% 信賴區間:0.07-0.33 )為影響治療後存活的相關因素。本研究發現肝腫瘤直徑較大且持續接受肝動脈栓塞與達到良好治療結果是影響晚期肝癌存活的預後因子。 The objective of our study is to evaluate the clinical efficacy and cost-effectiveness of combined treatment consisting of local radiotherapy for PVTT and TACE for advanced liver tumor.We also examined and compared the cost-effctiveness of this treatment combination with other therapeutic modalities.From March 2006 to December 2014, 96 patients with unresectable HCC complicated by Portal Vein Tumor Thrombosis (PVTT) were recruited as cases. All subjects received transarterial chemoembolization (TACE) and radiotherapy at Taichung Veterans General Hospital in Taiwan. Patient survival was estimated by Kaplan-Meier analysis. In multivariate analyses, the risk of patients’ mortality was estimated by hazard ratio (HR) in Cox proportional hazard regression model.HBV is the most common underlying hepatitis in the study population, with gender ratio favoring men over women. Multivariate analyses finds TACE treatment time (Hazard ratio [HR]:0.85; 95% confidence interval [CI]:0.75-0.96), maximum tumor diameter [HR: 1.10; 95% CI: 1.02-1.17], and post-TACE objective disease stabilization [HR:0.15; 95% CI:0.07-0.33] to be significantly associated with patients survival. And by combining these two therapeutic modalities we arrive at a mean total direct medical cost of NT133,000 for each patient.In combination, transarterial chemoembolization (TACE) and external beam radiation therapy (EBRT) proved effective as a means of enhancing tumor control in HCC patients with Portal Vein Tumor Thrombosis (PVTT), and achieved a high response rate. This combined regimen shows promise as an effective and safe treatment modality. Transarterial chemoembolization (TACE) combined radiotherapy is both a clinically valuable as well as cost-effective treatment option for patients of HCC complicated with Portal Vein Tumor Thrombosis (PVTT).
