| 摘要: | 本研究証明肝細胞癌(HCC)病人在經動脈血管化學栓塞術(TACE)前，若肝功能越差或肝硬化程度越嚴重，則治療後肝功能越差，肝臟損害越大。我們亦得知增加栓塞治療劑量，亦會提高治療後肝臟損害的危險。因此面對無法開刀的HCC病人，使用TACE的方法治療時，亦有與選擇開刀時同樣的困難要解決，也就是說要面對病人的疾病嚴重度。 在影響TACE後的肝臟損害的三個主要研究架構因素中，人口學較不重要，其中，年齡隨著肝硬化的進行而與GOT成負相關，因此在治療前單看GOT值是不足夠的。治療前靛氰綠15分鐘肝內殘留(ICG-R15)、凝血脢原時間及Child分級，為治療前預估病人肝臟損害的重要指標，因為病人的疾病嚴重程度因素引起肝臟損害的可能，遠大於治療時所使用劑量的因素。在TACE治療中所使用的三種治療藥物表柔比星、碘性油及止血棉，以碘性油的劑量對HCC患者無論是預測TACE後肝臟功能或TACE後的肝臟損害，都有著最顯著的影響。 我們發現有四成多的病人在TACE的治療後產生肝臟損害，其中有約16%的病人肝臟損害程度為ICG-R15上升超過5%，証明TACE的治療確實會造成肝臟不同程度的傷害，因此在考慮使用TACE去為HCC病人作治療時，必須經過嚴格篩選，一旦選擇TACE來作治療時，影響治療後肝臟損害最大的因素，就是碘性油的使用劑量。超過傳統保守碘性油劑量，雖然可以達到更有效的抗腫瘤效果，但是若碘性油使用劑量超過4-5毫升時，則相對增加Child分級對肝臟損害的效應。而且使用超過5毫升碘性油時，其引起肝臟損害的勝算比將大大增加，為對照組(少於5毫升碘性油)的3倍以上。因此面對HCC病人，若該腫瘤較大且具有較豐富的血管性時，若其肝硬化程度只有Child A或其治療前ICG-R15<20%，則建議以使用20-40毫升的碘化油作TACE的治療之用；但若病人治療前肝硬化程度已達Child B或C，或其治療前ICG-R15?20%，碘性油的使用劑量則不宜超過20毫升。; In this study, we proved that patient who has poorer liver function or more advanced stage of liver cirrhosis will have more liver damage after the treatment of Transarterial Chemoembolization (TACE). We also learn that the using of embolizers may cause higher risk of liver failure. In figuring out the way to treat inoperable HCC patient, we have the same dilemma as the surgeon does, i.e. to treat the patient out weight of the severity of the illness. Within the three possibility factors of our study framework, the socioeconomic factor is less related to the liver damage. Since the Age seemed to be a negative correlation with Aspartate transaminase (GOT) during the progress of the liver cirrhosis, we cannot use with the GOT data as the single predictor of patient’s condition. Since the severity of illness is a factor more important than TACE factors, the pre-TACE Indocyanine Green 15 minutes Retention Test (ICG-R15), prothrombin time, Child’s classification are the most important index to predict the liver damage of a patient after the TACE. Within the three kinds of drugs that we are using in the TACE, we find out that Lipiodol is the main variable to predict the post-TACE hepatic function as well as the degree of the liver damage. More than 40% patients in our study had liver damage after TACE, 16% patients even had ICG-R15 increased over 5%. This proved that the TACE have the adverse effect of liver damage. It is better to have a more careful selection before we plan to treat a HCC patient. In case of treating a HCC patient, then the most important factors to cause liver damage after TACE is the dosage of Lipiodol that we choose. The classical protocol of Lipiodol dosage may make safety treatment to smaller tumor; however, if you want to have more antitumor effect, the larger dosage may be needed. However, if you are using larger than 5ml of Lipiodol, the risk of causing liver damage is more than 3 times to the control group (use lesser than 5ml of Lipiodol). So, in case of treating a bigger tumor and with hypervascularity, 20-40ml Lipiodol is recommended for a Child A’s patient or patient have pre-TACE ICG-R15 lesser than 30%, but we should not use more than 20ml Lipiodol in TACE for a Child B/C patient or patient have pre-TACE ICG-R15 equal or more than 20%. |
