目的

探讨CEUS在晚期肝癌行免疫联合靶向治疗后疗效评价中的价值；探索CEUS定量分析在晚期肝癌行免疫联合靶向治疗后疗效评价中的价值；探索CEUS定量分析对晚期肝癌免疫联合靶向治疗近期疗效的预测价值。

材料和方法

收集2019年2月至2020年1月于中国医学科学院肿瘤医院肿瘤内科行免疫联合靶向治疗的晚期肝癌患者24例。全部24例患者于治疗前、免疫联合靶向治疗2周期后均行CEUS检查及腹部增强CT或MRI检查，其中20例患者于免疫联合靶向治疗4周期后完善了CEUS检查及腹部增强CT或MRI检查，检查结果疗效评价参照mRECIST进行。根据治疗结果将患者分为缓解组及未缓解组，缓解组包括接受免疫联合靶向治疗后达到CR及PR的晚期肝癌患者，未缓解组包括接受免疫联合靶向治疗后评价为SD及PD的晚期肝癌患者。对CEUS和增强CT/MRI评估晚期肝癌免疫联合靶向治疗后的疗效评价结果进行比较。

对免疫联合治疗前、治疗2周期及治疗4周期后不同时间点CEUS与增强CT/MRI所测得的肝癌病灶最大径线进行分析比较。通过使用GE LOGIQ E9超声诊断仪自带的定量分析软件对感兴趣病灶区域进行定量分析，得出治疗前及治疗2周期、治疗4周期后病灶区域内包括到达时间AT、TTP、PI、AUC、K在内的灌注参数。对比上述CEUS灌注参数在治疗前后的变化及其在治疗缓解组与未缓解组间的差异。

收集2019年2月至2020年1月于中国医学科学院肿瘤医院肿瘤内科行靶向联合免疫治疗的晚期肝癌患者20例于治疗前、治疗2周期行CEUS检查，分析得出相关参数，包括治疗前参数AT₀、TTP₀、PI₀、AUC₀、K₀，治疗2周期参数AT₂、TTP₂、PI₂、AUC₂、K₂，以及二者差值AT_△、TTP_△、PI_△、AUC_△、K_△。根据免疫联合靶向治疗4周期后依据mRECIST标准对靶病灶做出的放射影像学（增强CT/MRI）疗效评价结果，将患者分为缓解组（CR、PR）与未缓解组（SD、PD），分析对比两组间CEUS定量参数的差异。

结果

1.

1)免疫联合治疗前、治疗2周期、治疗4周期后CEUS所测得肿瘤最大径与CT/MRI所测得肿瘤活性病灶最大径均有较高的相关性（r=0.919、0.971、0.985，p均＜0.001）。

2)CEUS所得治疗2周期与4周期时肿瘤治疗的有效率与增强CT/MR所得肿瘤治疗有效率比较，二者之间无显著统计学差异（P=1.000，P=1.000）。

2.免疫联合靶向治疗2周期后，总计24例病灶中，4例肿瘤病灶缓解，20例肿瘤病灶未缓解；治疗4周期后，参与治疗的20例病灶中，5例肿瘤病灶评价为病情缓解，另15例评价为病情未缓解；

1）缓解组CEUS所测得的肿瘤最大径在免疫联合靶向治疗2周期及免疫联合靶向治疗4周期后均较治疗前减小（P=0.038，0.007），且免疫联合靶向治疗4周期后肿瘤最大径较治疗2周期后肿瘤最大径进一步减小（P=0.016）。

2）治疗2周期后，缓解组K较未缓解组低（P=0.049）。

3）超声造影参数中，治疗2周期与治疗前基线水平TTP、PI的差值在免疫联合治疗不同疗效组间差异有统计学意义（P=0.024，0.020）。

4）治疗4周期后，缓解组K较未缓解组低（P=0.011）。

5）超声造影参数中，免疫联合靶向治疗4周期与治疗前基线水平TTP、PI、AUC的差值在免疫联合治疗后缓解组与未缓解组间均存在统计学差异（P=0.045、0.003、0.016）。

3.接受4周期免疫联合靶向治疗的20例患者中，5例判定为病情缓解，15例判定为病情未缓解。

1）接受4周期免疫联合靶向治疗的患者，其治疗前与治疗2周期后CEUS定量参数的差值TTP_△、PI_△、AUC_△在不同组间的差异有统计学意义（P=0.023、0.007、0.040）。

2）治疗前与治疗2周期CEUS参数的差值中TTP_△与4周期后治疗效果呈正相关（r=0.504），治疗前与治疗2周期CEUS参数的差值中PI_△、AUC_△与4周期治疗后治疗效果呈负相关（r=-0.586，r=-0.463）。

3）Logistic回归分析显示PI_△可以作为预测晚期肝癌免疫联合靶向治疗疗效的预测指标（P=0.034）。ROC曲线显示PI_△的AUC值为0.920。当PI△的截断值设置在-2.8时，疗效预测的灵敏度和特异度分别为100%和80.0%。

结论

1.CEUS功能成像能够反应晚期肝癌免疫联合靶向治疗后的血流动力学的变化情况，有望为肝癌免疫联合靶向治疗后疗效评估提供新的方法。

2.免疫联合靶向治疗2周期后CEUS定量分析相关参数能够在一定程度上预测晚期肝癌免疫联合靶向治疗后的治疗反应，为患者的个体化治疗提供可靠依据。

Objective

The aims of this study were: 1)To investigate the value of contrast-enhanced ultrasound for evaluating the therapeutic efficacy of immunotherapy combined with targeted therapy in advanced HCC; 2) To investigate the value of quantitative analysis of CEUS for evaluating the therapeutic efficacy of immunotherapy combined with targeted therapy in advanced HCC; 3) To investigate the value of quantitative analysis of CEUS for evaluating the prognosis prediction of immunotherapy combined with targeted therapy for advanced advanced HCC.

Materials and Methods

A total of 24 patients with advanced HCC who received immunotherapy combined with targeted therapy in the Department of Medical Oncology, Cancer Hospital, Chinese Academy of Medical Sciences from February 2019 to January 2020 were collected. All the 24 patients underwent both CEUS examination and computed tomography or magnetic resonance imaging before treatment(n=24), after 2 cycles of treatment(n=24) and 4 cycles of treatment(n=20). Tumor response were evaluated according to the modified Response Evaluation Criterion, in which remission is defined with in complete response or partial response, and non-remission is defined with stable disease or progressive disease. The value of CEUS and the value of enhanced CT/MR for evaluating the therapeutic efficacy of immunotherapy combined with targeted therapy were compared.

The maximum diameter of each HCC lesion measured by CEUS at different time points before and after combination immunotherapy were analyzed and compared. Quantitative analysis of CEUS was evaluated using the software GE LOGIQ E9 Ultrasonic instrument. The time-intensity Curve of the regional organization according to the change of signal intensity in the region of interest with Time were collected. The tissue perfusion parameters of the lesion area were recorded before treatment, after 2 cycles of treatment and after 4 cycles of treatment, which includes the Arrive Time, the Time to Peak, the Peak Intensity, the Area Under Curve and K value.

The changes of the same CEUS parameters recorded at different time points were observed, and the differences of CEUS quantitative parameters between the remission group and the non-remission group were compared.

A total of 20 advanced HCC patients who received immunotherapy combinations in the Department of Medical Oncology, Cancer Hospital, Chinese Academy of Medical Sciences from February 2019 to January 2020 were collected for CEUS examination before and after 2 cycles of treatment, and relevant parameters were analyzed and obtained, including pre-treatment parameters AT₀, TTP₀, PI₀, AUC₀, K₀. and those after 2 cycles treatment AT₂, TTP₂, PI₂, AUC₂, K₂, and the difference between them AT_△, TTP_△, Pi_△, AUC_△, K_△. The therapeutic efficacy was evaluated according to enhanced CT/MRI examination after 4 cycles of treatment, and the patients were divided into remission group (including CR and PR) and non-remission group (including SD and PD) according to mRECIST criteria, and the differences in quantitative parameters of CEUS in HCC lesions in different groups were analyzed.

Results

1.

1) The maximum diameter of tumor measured by CEUS before treatment, after 2 cycles of treatment and after 4 cycles of treatment of immunotherapy combined with targeted therapy were similar with those measured by CT/MRI (r=0.919, 0.971, 0.985, P < 0.001, respectively).

2) There were no statistically significant differences in the efficacy evaluated by CEUS and that by enhanced CT/MR after 2 and 4 cycles of treatment (P=1.000 for both).

2.Among the 24 cases, after 2 cycles of treatment, 4 cases were judged to be in remission, and 20 cases were judged to be in non-remission. After 4 cycles of treatment, 5 of the 20 lesions were evaluated as remission, and 15 of them were in non-remission.

1) The tumor maximal diameter measured by CEUS in the remission group decreased after 2 cycles of immunotherapy combined with targeted therapy (P=0.038) and after 4 cycles after treatment (P=0.007), while the tumor maximal diameter in the remission group further decreased after 4 cycles of treatment compared with 2 cycles of treatment (P=0.016).

2) After 2 cycles of treatment, K value was significantly lower in the remission group than in the non-remission group (P=0.049).

3) After 2 cycles of treatment, the difference of TTP and PI of CEUS parameters

between two groups was significantly different (P=0.024，0.020).

4) After 4 cycles of treatment, K value was significantly lower in the remission group than in the non-remission group (P=0.011).

5) After 4 cycles of treatment, the difference of TTP, PI and AUC of CEUS parameters was significantly different between two groups (P=0.045, 0.003, 0.016, respectively).

3.Of the 20 patients, 5 were judged to be in remission and 15 were judged to be in non-remission after 4 cycles of combination immunotherapy.

1) The differences of parameters TTP_△, PI_△ and AUC_△ before treatment and 2 cycles of treatment were statistically significant among different treatment effects（P=0.023，0.007，0.040）.

2) TTP△ and therapeutic effect was positively correlated after 4 cycles of treatment (r=0.504), and a negative correlation between PI_△，AUC_△ and therapeutic effect after 4 cycles of treatment (r=-0.586, r=-0.463).

3) The AUC of PI_△ in the ROC curve was 0.920. When setting the critical point PI_△ at -2.8, the sensitivity and specificity for predicting treatment response were 100% and 80.0%, respectively.

Conclusions

1) CEUS functional imaging can reflect the changes of hemodynamics after immunotherapy combined with targeted therapy for advanced HCC, which is expected to provide a new method for efficacy evaluation after immunotherapy combinations for HCC.

2) Related parameters obtained by quantitative analysis of CEUS after 2 cycles of immuno-targeted combination therapy can predict the therapeutic effect after targeted combined immunotherapy for advanced HCC to a certain extent, and can provide a reliable basis for individualized treatment of patients.