간문맥혈전을 동반한 거대 간세포암종 환자에서 간동맥항암 단독요법과 동시 방사선-간동맥항암 병합요법의 효과 비교
Efficacy of Transarterial Chemolipiodolization with or without 3-Dimensional Conformal Radiotherapy for Huge HCC with Portal Vein Tumor Thrombosis
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목적: 간세포암종은 진단 당시 대부분 진행된 상태로 발견되며, 특히 간문맥 침습이 있는 경우, 간세포암종의 크기가 큰 경우는 예후가 불량하여 치료가 어려운 실정이다. 최근 간문맥 침습 간세포암종에 대한 동시 방사선-간동맥항암요법의 효과가 보고되고 있어, 본 연구에서는 기존의 간동맥항암요법과 동시 방사선-간동맥항암요법의 효과를 비교 분석 하였다. 대상과 방법: 가톨릭의대 부속 강남성모병원에서 2001년 3월부터 2004년 11월까지 간세포암종으로 진단된 환자 중 간문맥혈전증을 동반하고 크기가 8 cm 이상이며 TNM Ⅲ 또는 IVa, Child- Pugh 분류 A로 타장기 전이가 없으며, 4-6주 간격으로 2회 이상의 간동맥항암요법(adriamycin 50 mg/m2, cisplatin 60 mg/m2, 5-FU 200 mg/m2 간기능에 따른 조절된 용량)과 동시 방사선-간동맥항암요법을 받은 환자들을 후향 분석하였다. 동시 방사선-간동맥항암요법군에서는 간동맥색전술 시행 1주 뒤 총 4-5주에 걸쳐 총 40-45 Gy의 방사선 치료를 시행하였다. 치료 반응 평가는 간동맥항암요법을 시행한 후 매 1-2개월 간격으로 복부전산화단층촬영과 혈청 AFP를 측정하였고, 부작용을 조사하였다. 결과: 간동맥항암요법 단독치료군은 22명으로 평균 나이는 51세(31-78세), 남녀 비는 17:5였으며, 동시 방사선-간동맥항암요법 병합치료군은 27명으로 평균 나이는 56.8세(39-82세), 남녀 비는 23:4였다. 양군에서 간세포암종의 크기, AFP 수치, Child-Pugh 점수 및 등급의 차이는 없었다. 양군에서 3개월 치료 반응률은 18%, 48% (P=0.063)이고, 6개월째 치료 반응률은 10.5%, 42% (P=0.039)로 병합치료군에서 통계에서 높은 치료 반응을 보였다. 양군의 중앙생존기간은 각각 13개월과 13.5개월로 통계에서 생존기간의 차이는 없었으며, 6개월, 12개월 누적생존율도 90%, 54%와 93%, 62%로 차이는 없었다(P=0.502). 양군 간에서 간기능, 상부위장관, 혈액 부작용 발생의 차이는 없었다. 결론: 동시 방사선-간동맥항암요법 병합치료군이 간동맥항암요법 단독치료군에 비해서 치료 반응이 있었지만, 생존기간을 의미 있게 호전시키지 못하였다.
Abstract
Background/Aims: The treatment efficacy for advanced hepatocellular carcinoma is poor. This study examined the efficacy and toxicity of 3-dimensional conformal radiotherapy (3D-CRT) in combination with transarterial chemolipiodolization (TACL) for a huge hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT). Methods: From March 2001 to November 2004, 49 patients with advanced HCC with PVTT (size>8 cm, modified UICC stage IVa) were enrolled in this retrospective study. Twenty two patients underwent more than 2 cycles of TACL (adriamycin 50 mg/m2, cisplatin 60 mg/m2, 5-fluorouracil 200 mg/m2 every 4-6 weeks) without 3D-CRT, while 27 patients underwent consecutive TACL with 3D-CRT (40-45 Gy for 4-5 weeks) that was started one week after the 1st TACL. The response was assessed by a computed tomography (CT) and the serum alpha-fetoprotein (AFP) level at 1-2 month intervals. Results: The objective response rates in the TACL group and TACL with 3D-CRT group were 18% and 48% at 3 months (P=0.051), and 10.5% and 42% at 6 months (P=0.024) respectively. The median survival time was 13 months and 13.5 months in TACL and TACL with 3D-CRT groups, respectively (P=0.502). The treatment response was better in the TACL with 3D-CRT group but there was no significant difference in survival between the two groups. Most toxicities in the two groups were mild, not exceeding grade 1 according to the WHO criteria. Conclusions: For patients with a huge HCC with PVTT, TACL with 3D-CRT achieved some meaningful clinical benefit. Prospective controlled trials will be needed to confirm the real benefit of TACL combined with 3D-CRT. (Korean J Hepatol 2007;13:378-386)
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