病例:TACE+TAI+免疫+靶向,术后肝内多病灶复发肝癌患者疗效竟然达CR

2019-11-02 佚名 肿瘤资讯

原发性肝癌是常见的恶性肿瘤,根治性切除术是最有效的治疗方法之一,但术后复发转移是肝癌治疗面临的重要挑战,肝癌手术切除后5年复发转移率超过60%~70%,影响5年生存率的提升。对于术后复发的患者,应重视局部与全身治疗结合,控制疾病进展。本案例探讨一例经导管动脉栓塞化疗(TACE)术后肝动脉灌注化疗(TAI)联合免疫和靶向治疗,效果达到完全缓解的患者。

原发性肝癌是常见的恶性肿瘤,根治性切除术是最有效的治疗方法之一,但术后复发转移是肝癌治疗面临的重要挑战,肝癌手术切除后5年复发转移率超过60%~70%,影响5年生存率的提升。对于术后复发的患者,应重视局部与全身治疗结合,控制疾病进展。本案例探讨一例经导管动脉栓塞化疗(TACE)术后肝动脉灌注化疗(TAI)联合免疫和靶向治疗,效果达到完全缓解的患者。

病例介绍

基本情况

患者2018年9月无明显诱因出现上腹部疼痛,行影像学检查提示肝恶性肿瘤,行肝肿物切除术,术后病理提示肝细胞癌。2019年1月于当地医院行CT检查提示肝内弥漫性肝癌。

既往史:“乙肝”病史多年,未规律口服抗病毒治疗,具体用药不详。

查体:神志清楚,肝掌、蜘蛛痣(+),腹部平坦,腹软,全腹无压痛、反跳痛。

实验室检查:甲胎蛋白(AFP)>1210 ng/ml;WBC 6.77×109/L;HGB 115g/L;PLT 155g/L;AST 446 U/L;AST 75 U/L;TBIL 37.9 mmol/L;ABL 42.8 g/L;PT 13.2s;INR 0.99。

影像学检查:2019年1月25日,TACE术前CT检查示肝内弥漫多发病灶,门静脉通畅。

诊断:经实验室及影像学评估,初步诊断为:肝细胞癌(BCLC B期);乙肝肝硬化(Child-Pugh A)。

治疗过程

行抗病毒、护肝治疗,于2019年1月25日行第一次DEB-TACE(载药微球TACE)。

术中腹腔干造影:示肝内弥漫多发病灶,并肝动-门静脉瘘形成。

术中栓塞右前支肝动脉。栓塞材料为Hepasphere 30~60 μm 1#,负载吡柔比星 40 mg,4倍配法;Embosphere 300~500 μm 1#。

术后患者出现一过性肝功能受损,术后TBIL一过性上升至103 μmol/L,INR一过性上升至1.2。

2019年3月13日,即治疗后近7周复查CT:显示肝右叶部分病灶坏死,肝内仍有多发存活病灶。

经讨论后决定于2019年3月15日经皮锁骨下动脉药盒植入+cTACE(传统TACE),动脉药盒导管留置于肝固有动脉,cTACE后肝右叶散在碘油沉积。

术后分别于2019年3月16日、4月19日、5月31日经动脉药盒予mFOLFOX6方案化疗联合分子靶向药物索拉非尼 400mg bid,3月18日、4月22日、5月30日分别予信迪利单抗(达伯舒)200 mg静滴。

治疗后4个月,于2019年6月1日复查CT:显示肝内大部分病灶缩小、消失。

复查后维持现有治疗方案:7月13日、8月24日经动脉药盒予mFOLFOX6方案化疗;口服分子靶向药物索拉非尼400 mg bid;7月12日、8月24日信迪利单抗200 mg静脉滴注。

治疗7个月后,于2019年8月28日复查CT:疗效达完全缓解(CR)。

总结

患者为肝细胞癌手术切除后复发,初步检查CT显示肝内弥漫性多发病灶,肿瘤负荷大。肝功能尚良好,门静脉无癌栓,肝外无转移,符合BCLC B期。作为指南推荐最佳方案行DEB-TACE治疗。术后患者出现一过性肝功能明显受损,TACE术后复查肿瘤仍负荷大,未达到理想效果。行肝动脉灌注化疗联合靶向药物索拉非尼及信迪利单抗免疫治疗,疗效达CR,效果令人振奋。

专家点评

点评专家:中山大学附属第三医院介入科  黄明声 教授

原发性肝癌强调综合治疗原则,早期实施手术切除或者肝移植,中晚期也尽量采用TACE、局部消融、放疗、化疗及生物治疗等措施,使治愈率不断提高。对于不能手术切除的中晚期原发性肝癌患者,或可以手术切除但由于其他原因(如高龄、严重肝硬化等)不能或不愿接受手术的患者 ,肝动脉介入治疗可以作为首选方法。

肝动脉灌注化疗(TAI):在仔细分析造影表现,明确肿瘤的部位、大小、数目以及供血动脉后,超选择插管至肿瘤供血动脉内,将化疗药物直接注入肿瘤供血动脉,通过肝脏的首过效应最大程度地降低全身毒性反应。

肝动脉栓塞(TAE):一般采用超液化碘油与化疗药物充分混合成乳剂,也可以选用其他栓塞剂,如明胶海棉、永久性颗粒和微球等。对于肝癌合并动静脉瘘者,应该注意首先要有效地栓堵动静脉瘘,再进行针对肿瘤的TAE,以防止引起肺栓塞等严重并发症和保证抗肿瘤TAE的效果;对于重度动静脉瘘者,一般主张仅采取TAI治疗。

TACE:是同时进行TAI和 TAE治疗的方式。TACE治疗肝癌主要是基于肝癌和正常肝组织血供的差异,即95%~99%的肝癌血供来自肝动脉,而正常肝组织血供的70%~75%来自门静脉,肝动脉血供仅占20%~25%。TACE能有效阻断肝癌的动脉供血,同时持续释放高浓度的化疗药物打击肿瘤,使其缺血坏死并缩小,而对正常肝组织影响较小。循证医学证据业已表明TACE能有效控制肝癌生长,明显延长患者生存期,使肝癌患者获益,已成为不能手术切除的中晚期或术后复发肝癌患者首选和最有效的治疗方法。由于肝细胞癌多发生在有慢性肝病或者肝硬化疾病的基础上,预后较差,治疗复杂,因此特别强调多学科规范化的综合治疗,提倡针对不同的患者或者同一患者的不同阶段实施个体化治疗。对于无血管受侵,肿瘤数目4个以上无肝外转移的肝功能评级为Child-Pugh A或B的患者建议行TACE控制肝脏肿瘤,一般不宜首先考虑手术切除治疗。本例患者为肝癌术后复发,术后4个月复查,可见肝脏弥漫性病灶。TACE术前患者肝功能评价Child-Pugh A级,门脉通畅,符合TACE治疗的指征。在肝细胞癌选择治疗方法时,应该强调对于基础肝病(慢性乙型肝炎、肝硬化和肝功能障碍)的治疗,在进行手术切除或肝移植、局部消融、TAI/TACE、放疗以及系统治疗(分子靶向药物治疗和化疗)时,宜注意检查和监测病毒载量,可以考虑预防性应用抗病毒药物;同时,在肝切除术后,也提倡进行规范的抗病毒治疗。本病例患者在行TACE治疗前进行了充分的肝脏功能的评估,并且进行抗病毒及保肝药物治疗,虽然在首次TACE治疗后肝功能出现一过性受损,但并未出现严重不良反应。

TACE治疗近2月后复查,肝右叶部分病灶坏死,但是肝内仍有多发存活病灶。该患者肿瘤负荷较大,基于患者此时的肝功能和全身情况较好,应考虑更为积极的治疗方案。因此,在经过充分讨论后,考虑在TACE基础上,联合系统治疗。最终决定于2019年3月15日再次行cTACE并行经皮锁骨下动脉药盒植入,以方便后续药物治疗。

当前的肝癌一线系统治疗选择中,主要是靶向药物索拉非尼和仑伐替尼,但这两种药物单药使用的有效率都相当有限。新兴的免疫治疗也已进入肝癌的治疗,如纳武利尤单抗和帕博利珠单抗已获FDA批准用于肝癌二线治疗,但免疫单药的有效率也仅限于15%~20%。近期,陆续有研究开始探索免疫治疗联合靶向治疗的疗效,并取得了不错的初期成果,如2019年AACR大会上报道的仑伐替尼+PD-1单抗帕博利珠单抗治疗晚期不可切除肝细胞癌患者的Ⅰb期研究KEYNOTE-524中,研究者和独立第三方影像学评估的完全缓解(CR)率分别为3.3%和10%,客观缓解率(ORR)分别为36.7%和50%。中位无进展生存期为 9.7个月。近期,仑伐替尼+帕博利珠单抗用于晚期肝癌一线治疗已获美国FDA突破性疗法认定。

肝癌的治疗强调多学科综合治疗,重视局部与全身治疗的结合。2019年,中山大学附属肿瘤医院石明教授的一项以FOLFOX方案行TAI联合索拉非尼对比索拉非尼单药用于门静脉侵犯的肝细胞癌的Ⅲ期研究显示,索拉非尼联合TAI的疗效更佳且副反应可控。TACE与抗血管生成靶向药物联合也有协同作用,TACE治疗后会导致肿瘤细胞及周围组织缺氧,进而促进新生血管形成,使得肿瘤易于复发、转移。而抗血管生成靶向药物可能会降低TACE术后VEGFR的水平,从而在治疗上达到与TACE互补的作用。TACTICS研究已经证实了TACE联合索拉非尼较单用TACE对于中期肝细胞癌的疗效优势。TACE联合免疫治疗也是较有前景的组合,该组合可以增强局部肿瘤控制和全身抗肿瘤效果。目前,TACE联合免疫治疗正在进行相关的研究探索。一项ⅠB期研究正在评估TACE后接受帕博利珠单抗的安全性和疗效;另一项Ⅱ期研究IMMUTACE则评估TACE联合纳武利尤单抗治疗中期肝癌。

综合上述研究结果,我们在该患者单用DEB-TACE疗效欠佳后,基于患者肝功能良好,选用了cTACE+TAI+靶向治疗+免疫治疗。靶向药物选用了经典的一线用药索拉非尼,免疫药物选用了国产的信迪利单抗,因信迪利单抗较进口药物更具价格优势,且已于2018年在中国获准用于复发/难治性霍奇金淋巴瘤的治疗。其在各个瘤种临床治疗及临床试验中也展示了不俗的成绩。2018年CSCO会议发布的的一项Ⅰ期临床研究显示,信迪利单抗对晚期肝细胞肝癌的ORR达到15.7%,表现出与帕博利珠单抗、纳武利尤单抗类似的疗效特征,总体的安全性与耐受性良好。

这例患者cTACE术后选择了mFOLFOX6肝动脉灌注化疗联合索拉非尼加信迪利单抗的三联方案,结果不负众望,展现出神奇的效果,在治疗3个周期后,肝内大部分病灶缩小消失,肿瘤指标明显下降,最终达到CR。

这一患者的诊疗历程提醒我们,在临床诊疗过程中,对于特殊病例,需要根据现有数据进行一些创新性的选择,为患者带来最大获益。

黄明声 教授,主任医师 医学博士 博士生导师,中山大学附属第三医院介入科主任,中山大学附属第三医院岭南院区介入血管科主任,中华放射学会介入学组青年工作组副组长,中国医学-介入整合联盟常务理事,中国抗癌协会肿瘤微创治疗专业委员会肝癌微创治疗与多学科综合治疗分会副主任委员,中国医师协会介入医师分会急诊专业委员会委员,IUA内脏动脉疾病专家委员会委员,中国医师协会内脏动脉疾病专家委员会委员,中国医师协会肝癌专委会介入委员会委员,广东省抗癌协会肿瘤微创介入专业委员会第三届委员会副主任委员,广东省抗癌协会肿瘤微创介入专业委员会副主任委员,中国抗癌协会第三届肿瘤介入学专业委员会委员,中国抗癌协会肿瘤介入学专业委员会消融专家委员会委员,广东省健康管理学会介入专委会副主任委员,广东省医学会肝癌分会介入治疗学组委员,广东省医学会介入医学分会委员,广东省医师协会介入医师分会委员 .

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#插入话题
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  2. [GetPortalCommentsPageByObjectIdResponse(id=2053550, encodeId=d45b205355099, content=<a href='/topic/show?id=387c6109e6a' target=_blank style='color:#2F92EE;'>#术后肝内多病灶#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=61097, encryptionId=387c6109e6a, topicName=术后肝内多病灶)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8306486, createdName=小刀医生, createdTime=Sat Mar 21 09:10:00 CST 2020, time=2020-03-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1969029, encodeId=5ee0196902956, content=<a href='/topic/show?id=4dd7812e8f3' target=_blank style='color:#2F92EE;'>#肝癌患者#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=81278, encryptionId=4dd7812e8f3, topicName=肝癌患者)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=3609256, createdName=zhu_jun9837, createdTime=Tue Jun 02 16:10:00 CST 2020, time=2020-06-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2033715, encodeId=cb552033e15f1, content=<a href='/topic/show?id=fc431e0708f' target=_blank style='color:#2F92EE;'>#TAC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=20, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=17070, encryptionId=fc431e0708f, topicName=TAC)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b05b180, createdName=grace5700, createdTime=Thu Apr 23 13:10:00 CST 2020, time=2020-04-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1655978, encodeId=a48816559e82e, content=<a href='/topic/show?id=2a011829d7' target=_blank style='color:#2F92EE;'>#ACE#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=1829, encryptionId=2a011829d7, topicName=ACE)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=635024767990, createdName=shanyongle, createdTime=Mon May 25 18:10:00 CST 2020, time=2020-05-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1032320, encodeId=264710323205c, content=谢谢梅斯提供这么好的信息,学到很多, beContent=null, objectType=article, channel=null, level=null, likeNumber=49, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=内科新手, createdTime=Sat Nov 02 18:10:00 CST 2019, time=2019-11-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1040240, encodeId=58591040240f1, content=肝癌,接下来就要细分了,对于体质好的病人,能否将PD-1类+抗血管新生+放疗等相结合,甚至有必要用TACE进行减负, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=留走人康, createdTime=Sat Nov 02 18:10:00 CST 2019, time=2019-11-02, status=1, ipAttribution=)]
  3. [GetPortalCommentsPageByObjectIdResponse(id=2053550, encodeId=d45b205355099, content=<a href='/topic/show?id=387c6109e6a' target=_blank style='color:#2F92EE;'>#术后肝内多病灶#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=61097, encryptionId=387c6109e6a, topicName=术后肝内多病灶)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8306486, createdName=小刀医生, createdTime=Sat Mar 21 09:10:00 CST 2020, time=2020-03-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1969029, encodeId=5ee0196902956, content=<a href='/topic/show?id=4dd7812e8f3' target=_blank style='color:#2F92EE;'>#肝癌患者#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=81278, encryptionId=4dd7812e8f3, topicName=肝癌患者)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=3609256, createdName=zhu_jun9837, createdTime=Tue Jun 02 16:10:00 CST 2020, time=2020-06-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2033715, encodeId=cb552033e15f1, content=<a href='/topic/show?id=fc431e0708f' target=_blank style='color:#2F92EE;'>#TAC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=20, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=17070, encryptionId=fc431e0708f, topicName=TAC)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b05b180, createdName=grace5700, createdTime=Thu Apr 23 13:10:00 CST 2020, time=2020-04-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1655978, encodeId=a48816559e82e, content=<a href='/topic/show?id=2a011829d7' target=_blank style='color:#2F92EE;'>#ACE#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=1829, encryptionId=2a011829d7, topicName=ACE)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=635024767990, createdName=shanyongle, createdTime=Mon May 25 18:10:00 CST 2020, time=2020-05-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1032320, encodeId=264710323205c, content=谢谢梅斯提供这么好的信息,学到很多, beContent=null, objectType=article, channel=null, level=null, likeNumber=49, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=内科新手, createdTime=Sat Nov 02 18:10:00 CST 2019, time=2019-11-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1040240, encodeId=58591040240f1, content=肝癌,接下来就要细分了,对于体质好的病人,能否将PD-1类+抗血管新生+放疗等相结合,甚至有必要用TACE进行减负, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=留走人康, createdTime=Sat Nov 02 18:10:00 CST 2019, time=2019-11-02, status=1, ipAttribution=)]
    2020-04-23 grace5700
  4. [GetPortalCommentsPageByObjectIdResponse(id=2053550, encodeId=d45b205355099, content=<a href='/topic/show?id=387c6109e6a' target=_blank style='color:#2F92EE;'>#术后肝内多病灶#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=61097, encryptionId=387c6109e6a, topicName=术后肝内多病灶)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8306486, createdName=小刀医生, createdTime=Sat Mar 21 09:10:00 CST 2020, time=2020-03-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1969029, encodeId=5ee0196902956, content=<a href='/topic/show?id=4dd7812e8f3' target=_blank style='color:#2F92EE;'>#肝癌患者#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=81278, encryptionId=4dd7812e8f3, topicName=肝癌患者)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=3609256, createdName=zhu_jun9837, createdTime=Tue Jun 02 16:10:00 CST 2020, time=2020-06-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2033715, encodeId=cb552033e15f1, content=<a href='/topic/show?id=fc431e0708f' target=_blank style='color:#2F92EE;'>#TAC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=20, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=17070, encryptionId=fc431e0708f, topicName=TAC)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b05b180, createdName=grace5700, createdTime=Thu Apr 23 13:10:00 CST 2020, time=2020-04-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1655978, encodeId=a48816559e82e, content=<a href='/topic/show?id=2a011829d7' target=_blank style='color:#2F92EE;'>#ACE#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=1829, encryptionId=2a011829d7, topicName=ACE)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=635024767990, createdName=shanyongle, createdTime=Mon May 25 18:10:00 CST 2020, time=2020-05-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1032320, encodeId=264710323205c, content=谢谢梅斯提供这么好的信息,学到很多, beContent=null, objectType=article, channel=null, level=null, likeNumber=49, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=内科新手, createdTime=Sat Nov 02 18:10:00 CST 2019, time=2019-11-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1040240, encodeId=58591040240f1, content=肝癌,接下来就要细分了,对于体质好的病人,能否将PD-1类+抗血管新生+放疗等相结合,甚至有必要用TACE进行减负, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=留走人康, createdTime=Sat Nov 02 18:10:00 CST 2019, time=2019-11-02, status=1, ipAttribution=)]
    2020-05-25 shanyongle
  5. [GetPortalCommentsPageByObjectIdResponse(id=2053550, encodeId=d45b205355099, content=<a href='/topic/show?id=387c6109e6a' target=_blank style='color:#2F92EE;'>#术后肝内多病灶#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=61097, encryptionId=387c6109e6a, topicName=术后肝内多病灶)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8306486, createdName=小刀医生, createdTime=Sat Mar 21 09:10:00 CST 2020, time=2020-03-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1969029, encodeId=5ee0196902956, content=<a href='/topic/show?id=4dd7812e8f3' target=_blank style='color:#2F92EE;'>#肝癌患者#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=81278, encryptionId=4dd7812e8f3, topicName=肝癌患者)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=3609256, createdName=zhu_jun9837, createdTime=Tue Jun 02 16:10:00 CST 2020, time=2020-06-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2033715, encodeId=cb552033e15f1, content=<a href='/topic/show?id=fc431e0708f' target=_blank style='color:#2F92EE;'>#TAC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=20, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=17070, encryptionId=fc431e0708f, topicName=TAC)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b05b180, createdName=grace5700, createdTime=Thu Apr 23 13:10:00 CST 2020, time=2020-04-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1655978, encodeId=a48816559e82e, content=<a href='/topic/show?id=2a011829d7' target=_blank style='color:#2F92EE;'>#ACE#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=1829, encryptionId=2a011829d7, topicName=ACE)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=635024767990, createdName=shanyongle, createdTime=Mon May 25 18:10:00 CST 2020, time=2020-05-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1032320, encodeId=264710323205c, content=谢谢梅斯提供这么好的信息,学到很多, beContent=null, objectType=article, channel=null, level=null, likeNumber=49, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=内科新手, createdTime=Sat Nov 02 18:10:00 CST 2019, time=2019-11-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1040240, encodeId=58591040240f1, content=肝癌,接下来就要细分了,对于体质好的病人,能否将PD-1类+抗血管新生+放疗等相结合,甚至有必要用TACE进行减负, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=留走人康, createdTime=Sat Nov 02 18:10:00 CST 2019, time=2019-11-02, status=1, ipAttribution=)]
    2019-11-02 内科新手

    谢谢梅斯提供这么好的信息,学到很多

    0

  6. [GetPortalCommentsPageByObjectIdResponse(id=2053550, encodeId=d45b205355099, content=<a href='/topic/show?id=387c6109e6a' target=_blank style='color:#2F92EE;'>#术后肝内多病灶#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=61097, encryptionId=387c6109e6a, topicName=术后肝内多病灶)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8306486, createdName=小刀医生, createdTime=Sat Mar 21 09:10:00 CST 2020, time=2020-03-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1969029, encodeId=5ee0196902956, content=<a href='/topic/show?id=4dd7812e8f3' target=_blank style='color:#2F92EE;'>#肝癌患者#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=81278, encryptionId=4dd7812e8f3, topicName=肝癌患者)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=3609256, createdName=zhu_jun9837, createdTime=Tue Jun 02 16:10:00 CST 2020, time=2020-06-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2033715, encodeId=cb552033e15f1, content=<a href='/topic/show?id=fc431e0708f' target=_blank style='color:#2F92EE;'>#TAC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=20, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=17070, encryptionId=fc431e0708f, topicName=TAC)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b05b180, createdName=grace5700, createdTime=Thu Apr 23 13:10:00 CST 2020, time=2020-04-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1655978, encodeId=a48816559e82e, content=<a href='/topic/show?id=2a011829d7' target=_blank style='color:#2F92EE;'>#ACE#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=1829, encryptionId=2a011829d7, topicName=ACE)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=635024767990, createdName=shanyongle, createdTime=Mon May 25 18:10:00 CST 2020, time=2020-05-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1032320, encodeId=264710323205c, content=谢谢梅斯提供这么好的信息,学到很多, beContent=null, objectType=article, channel=null, level=null, likeNumber=49, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=内科新手, createdTime=Sat Nov 02 18:10:00 CST 2019, time=2019-11-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1040240, encodeId=58591040240f1, content=肝癌,接下来就要细分了,对于体质好的病人,能否将PD-1类+抗血管新生+放疗等相结合,甚至有必要用TACE进行减负, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=留走人康, createdTime=Sat Nov 02 18:10:00 CST 2019, time=2019-11-02, status=1, ipAttribution=)]
    2019-11-02 留走人康

    肝癌,接下来就要细分了,对于体质好的病人,能否将PD-1类+抗血管新生+放疗等相结合,甚至有必要用TACE进行减负

    0