陳潔 綜述 黎樂群 審校
(廣西醫(yī)科大學(xué)附屬腫瘤醫(yī)院 肝膽外科,廣西 南寧 530021)
肝細胞癌(HCC)是世界上最常見的惡性腫瘤之一,特別是我國廣西地區(qū),腫瘤致死率高居第三位[1],該腫瘤具有侵襲肝內(nèi)血管的傾向,導(dǎo)致肝內(nèi)和肝外轉(zhuǎn)移[2]。外科手術(shù)治療和肝移植(LT)是目前最主要的HCC治療手段[3],然而,手術(shù)切除和肝移植的預(yù)后仍無法達到預(yù)期效果,其中最需要克服的難題就是術(shù)后復(fù)發(fā)[4]。手術(shù)切除后、肝移植后5年復(fù)發(fā)率分別高達70%、35%[5]。大血管侵犯和微血管侵犯(microvascular invasion,MVI)均與腫瘤分期和疾病進展有關(guān)。通常大血管腫瘤侵犯可通過影像學(xué)檢查確診[6]。MVI是HCC發(fā)生發(fā)展過程中出現(xiàn)的一種病理征象,是腫瘤早期轉(zhuǎn)移的標志[7]。但MVI的臨床意義常被低估,認為MVI是一種較為溫和的腫瘤侵襲形式,隨著對MVI的研究認識和其對預(yù)后的不良影響,MVI已經(jīng)成為HCC研究的熱門話題,而目前僅能通過術(shù)后標本的組織病理學(xué)檢查診斷[8],這對于術(shù)前治療方案的制定具有滯后性。因此,術(shù)前合理預(yù)測MVI對HCC患者個體化治療方案的制定及其遠期預(yù)后的評估具有重要意義[9]。本文綜合近年來對HCC術(shù)前預(yù)測MVI的文獻報道,予以綜述。
MVI的診斷標準尚未統(tǒng)一。Sumie等[10]指出只要在門靜脈或肝靜脈系統(tǒng)發(fā)現(xiàn)腫瘤細胞即可診斷為MVI。不過,他們沒有考慮到膽管和淋巴管侵犯以及血管侵犯到腫瘤邊緣的距離。目前,較多學(xué)者[11]對MVI定義為顯微鏡下于內(nèi)皮細胞襯覆的血管腔內(nèi)見到癌細胞巢團的觀點表示認可。MVI是一種由多因素參與導(dǎo)致的復(fù)雜的生物過程,包括HCC與微環(huán)境的相互作用,以及與宿主狀態(tài)(免疫、內(nèi)分泌和代謝等)[12]。目前機制尚未明確。
大量研究[13]表明MVI可反映HCC早期轉(zhuǎn)移能力和侵襲程度,并且可作為HCC預(yù)后的獨立危險因素。在HCC合并MVI時,患者總生存率及3年無復(fù)發(fā)率都將縮短[3,14]。近年來對MVI的研究越來越具體化,主要集中在MVI多發(fā)位置、對微血管侵犯程度以及微血管數(shù)目等[15-17];Parfitt等[18]研究甚至將淋巴管侵犯也歸納為MVI。隨著對MVI研究范圍的擴展,目前報道的HCC的MVI發(fā)生率明顯升高。Lim等[19]通過對225例HCC切除術(shù)患者的調(diào)查研究發(fā)現(xiàn),MVI陽性組中位復(fù)發(fā)時間(12.0個月)顯著低于MVI陰性組(42.2個月);Hou等[20]研究結(jié)果表明,MVI不僅是限制首次術(shù)后生存的危險因素(HR=2.62,95% CI為2.15~3.19),再次手術(shù)也具有同樣重要作用(2次術(shù)前MVI均陽性:HR=4.79,95% CI=2.54~9.53;首次術(shù)前MVI陰性、再次復(fù)發(fā)術(shù)前MVI陽性:HR=4.02,95% CI=2.27~7.13)。<2 cm早期小HCC通常認為手術(shù)切除的預(yù)后效果較好[21],但Yamashita等[22]研究149例<2 cm早期小HCC中發(fā)現(xiàn)43例合并MVI的患者接受HCC切除后,1年復(fù)發(fā)率為23.3%,顯著大于不伴有MVI的復(fù)發(fā)率(7.5%)。Roayaie等[23]研究證實擴大手術(shù)切緣(>1 cm)可以減少HCC伴有MVI患者的腫瘤復(fù)發(fā)。Zhou等[24]研究也表明肝解剖切除可見降低HCC并MVI患者的術(shù)后復(fù)發(fā)率。因此,如果術(shù)前可以確定MVI的風險,可以術(shù)前做出解剖切除或非解剖切除以及手術(shù)切緣的寬度的合理選擇,在術(shù)中更具針對性的外科治療策略,對提高生存時間具有重要價值[25-26]。
目前,MVI的診斷主要依靠手術(shù)標本的病理檢查。術(shù)前肝臟穿刺活檢診斷MVI準確性低,不確定因素多,且屬于有創(chuàng)檢查,患者接受度差。由此導(dǎo)致的結(jié)果就是,由于無法依據(jù)MVI信息制定擴大肝切緣的治療方案,具有明顯的滯后性,使患者失去延長生存期的機會[27]。同時,MVI常發(fā)生于晚期HCC患者,而在早期HCC中發(fā)生率相對較低,然而早期HCC才是接受根治性治療的最佳適應(yīng)指征,因此術(shù)前預(yù)測早期HCC MVI有著更大的臨床應(yīng)用價值。隨著診療設(shè)備及醫(yī)學(xué)理論的發(fā)展,MVI的術(shù)前預(yù)測也得到巨大進步,目前比較公認的檢測方法主要為影像學(xué)、血清學(xué)及信號通路檢查。
CT是最早用于預(yù)測HCCMVI的影像學(xué)方法之一。Eguch等[28]研究表明,HCC瘤灶單節(jié)結(jié)型較之于其他分型HCC(多節(jié)結(jié)型或單結(jié)節(jié)結(jié)外生長型)發(fā)生MVI的風險率更低。張俊等[29]研究進一步指出,HCC的常見CT征象(腫瘤最大直徑、癌組織邊緣強化程度、腫瘤包膜及腫瘤形態(tài))中,只有腫瘤形態(tài)對預(yù)測MVI有意義,其診斷的靈敏度、特異度、準確率分別為76.7%、75.0%、76.0%。此外,李文柱團隊[30]還驗證了能譜CT對預(yù)測微血管侵犯的可行性,該研究指出動脈期標準碘基值(NIC-a)與HCC微血管密度(MVD)呈中度相關(guān)(r=0.507,P<0.05)。楊創(chuàng)勃等[31]也發(fā)現(xiàn)能譜CT掃描對評估微血管侵犯具有重要價值,進一步證實能譜CT碘基值與微血管侵犯的相關(guān)性。Banerjee等[5]研究更是將CT對MVI的預(yù)測延生到分子影像學(xué)層面,該實驗通過CT靶向性MVI高危基因(91-gene)來評估靜脈侵潤程度(RVI),并利用RVI診斷MVI的準確率、靈敏度、特異度分別為89%、76%、94%,RVI陰性組3年HCC切除術(shù)后無復(fù)發(fā)率為62%,較之RVI陽性組(無復(fù)發(fā)率27%)高出1倍以上。可見,CT對HCC形態(tài)學(xué)的判斷以及MVI分子標記物的示蹤,為MVI的預(yù)測提供了一個新的思路,在臨床醫(yī)師制定HCC治療策略時應(yīng)該特別注意。
MRI因其較高的軟組織分辨率及功能成像的日漸成熟,該技術(shù)用于MVI的預(yù)測的研究也得到較大進展。Chandarna等認為[32],HCC瘤灶形態(tài)的不規(guī)則是預(yù)測MVI得唯一指標,包括病理及AFP在內(nèi)的其他臨床特征都與MVI不相關(guān)。MRI對HCCMVI的預(yù)測除了依據(jù)瘤灶形態(tài)學(xué)指征外,MRI功能學(xué)成像同樣具有重要診斷價值。Xu等[33]利用磁共振擴散加權(quán)成像對HCC微血管侵犯的研究結(jié)果表明,以表觀彌散系數(shù)(ADC)<1.227×10-3s/mm2作為最佳診斷閾值時,其靈敏度、特異度分別為66.7%、78.6%。Renzulli等[34]研究表明,同時存在HCC的3個危險征象(腫瘤邊緣不光整、邊緣強化以及靜脈侵潤)時,在不計腫瘤大小的情況下,其診斷陽性預(yù)測值可達95%。由此可知,MRI對HCCMVI的預(yù)測同樣具有重要價值。
該方法主要是檢測血清中某種HCC特異性抗原表達量來預(yù)測MVI發(fā)生,現(xiàn)在研究較多的有異常凝血酶原(DCP)和AFP等。Poté等[35]發(fā)現(xiàn)HCC患者血清DCP>90 mAU/mL可作為MVI的獨立預(yù)測因素(HR=3.5,95% CI=1.08~11.8),該診斷閾值對應(yīng)的靈敏度、特異度分別為70%、63%,若聯(lián)合組織DCP檢查,則靈敏度、特異度可提高到87%、90%。Dumitra等[36]研究發(fā)現(xiàn)AFP斜率對預(yù)測MVI及HCC的復(fù)發(fā)具有重要意義。Zhao等[37]以多結(jié)節(jié)HCC進行亞組分析,發(fā)現(xiàn)GGT>130 U/L時,MVI陽性率比MVI陰性率高出1倍多。這種方案局限性是特異性不強,例如DCP和AFP在慢性肝炎和肝硬化等非HCC患者的血清同樣呈高表達[38],容易造成診斷重疊。目前尚未發(fā)現(xiàn)對MVI特異的血清蛋白標志物。
這一思路的創(chuàng)新性在于著眼于HCC發(fā)生機制,通過對病理組織的樣本檢測,發(fā)現(xiàn)與HCC關(guān)系密切的信號通道基因或蛋白發(fā)生了改變,這其中的一些分子生物學(xué)指標被認為與MVI的存在有關(guān)[39]。Poté等[40]利用質(zhì)譜成像發(fā)現(xiàn)組蛋白4的修飾物(H4K16ac與H4K20me2)在MVI陽性組高表達,明顯不同于MVI陰性組。Yu等[41]發(fā)現(xiàn)抗血清熱休克蛋白70在MVI陰性患者中顯著高于MVI陽性患者,由此推測抗血清熱休克蛋白70可作為MVI陰性患者血清學(xué)標志物。Ding等[42]應(yīng)用Li-鈣黏蛋白(Li-cadherin)與其他黏附分子結(jié)合,預(yù)測HCC患者的MVI和預(yù)后。Mínguez等[43]發(fā)現(xiàn)了35個基因標記(14個基因高表達和21個基因低表達)與血管侵犯有關(guān),對MVI預(yù)測的準確度為69%??紤]到低特異性、技術(shù)復(fù)雜性和高成本,這些方法仍處于研究階段,在目前較短時間內(nèi)難以將基礎(chǔ)研究轉(zhuǎn)化為臨床應(yīng)用[44]。
綜上所述,MVI對HCC的治療方式及預(yù)后發(fā)展都有著重大作用,現(xiàn)有的MVI術(shù)前預(yù)測技術(shù)各有所長又各有短板,故而在臨床推廣應(yīng)用上應(yīng)該綜合考慮,使得建立一個整合多個預(yù)測因子的臨床預(yù)測模型逐漸成為現(xiàn)實,為減低HCC患者術(shù)后復(fù)發(fā)及轉(zhuǎn)移,改善患者預(yù)后等方面帶來福祉。
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