继发性肝癌的联合治疗

采用手术切除联合术后Ｂ超引导肝内门静脉区域化疗（简称ＰＨＰＣ）治疗胃肠道癌异时肝转移２４例。随访４￣５４个月，结果：术后经３个疗程的ＰＨＰＣ，８例已存活１８￣４８个月；１３例分别经过２￣１１次的ＰＨＰＣ，已存活５￣３９个月；另３例死亡。作者认为，对继发性肝癌采用手术切除配合术后Ｂ超引导的ＰＨＰＣ是一种延长患者生存期的有效联合治疗方案。     

胰腺钩突肿瘤的外科手术治疗(附1O例报告)

目的 总结胰腺钩突肿瘤的临床特点及提高手术切除率的措施。方法 对10例胰腺钩突肿瘤行根治性手术治疗，其中7例联合PV、SMV切除，3例行经典的Whipple手术。7例联合血管切除术中，5例切除静脉干长度为2．0～4．2cm，直接对端吻合成功，2例行受浸润血管侧壁切除修补术。门脉阻断时间最长40min，最短8min，未同时阻断SMA。结果 联合PV、SMV切除的7例中，有1例术后3d肝功能衰竭死亡，1例未行脾静脉与SMV吻合，术后出现大量乳糜样腹水，经治疗40d痊愈，术后存活20个月，余5例术后生存13～29个月。未联合静脉切除的3例中，2例分别存活13个月、14个月，l例已存活11．5个月至今健在，无癌肿复发。结论 胰腺钩突肿瘤具有缺乏早期症状和邻近血管早期受侵两个特点；门脉浸润不是根治手术禁忌证；联合PV、SMV切除4～5cm以内直接对端吻合是可行的。     

多电极射频疗法治疗晚期胰腺癌8例报告

总结分析3年来术中采用B超引导下多电极射频结合内引流术治疗8例不能手术切除的晚期胰腺癌患者的临床资料。结果示：8例均未出现严重并发症；8例术后均获随访，随访时间为12～35个月，平均存活l6个月。其中10～12个月死亡4例，另4例现已分别带瘤生存10个月，15个月，24个月，35个月。提示多电极射频治疗晚期胰腺癌在一定程度上可延长患者生存期，提高生存质量，是一种较有效的治疗方法。     

中晚期肝癌联合介入治疗175例报道

目的 应用联合微创介入方法治疗中晚期肝癌并探讨其疗效.方法 我院自1998年4月至2008年11月期间采用联合介入治疗的方法,即行经皮股动脉插管肝动脉化疗栓塞术,同期行B超引导下经皮穿刺瘤内乙醇注射(PEI)治疗中晚期肝癌175例.结果 左肝动脉行肝动脉化疗栓塞7例,右肝动脉行125例,单行化疗而未栓塞43例;175例均行B超引导下PEI.随访6～28个月,平均19.3个月,死亡15例,其中8例死于肝功能衰竭,7例死于上消化道大出血伴肝癌广泛转移.29例存活6～12个月;146例存活13～28个月,其中27例存活已超过26个月.结论 对于不能切除的中晚期肝癌采用联合介入治疗,因其具有操作简单、疗效可靠、经济、安全等优点,值得临床推广应用.     

原发性肝细胞癌自发性破裂的治疗(附64例报告)

目的 探讨原发性癌自发性破裂（SRHCC）的治疗方法。方法 回顾性分析64例SRHCC病人非手术及手术治疗的疗效。结果 保守治疗14例（21.9%），平均存活时间7d(12h～12d)；手术治疗50例（78.1%），其中长纱布填塞31例（48.4%），平均存活时间11d（4h～3个月），1个月存活率3.2%；肝动脉结扎6例（9.4%），平均存活2.5个月（8d～6个月），1个月存活率66.7%；肝动脉栓塞化疗病人1例（1.6%），存活9d；肝切除12例（18.8%），1个月存活率91.7%，1，3，5年存活率分别为66.7%,16.7%，8.3%，平均存活时间36个月（4d～25年3个月），最长1例存活超过25年3个月，目前仍键在。肝切除组中11例Child-Pugh功能A级病人安全度过围手术期，无死亡；1例Child-Pugh功能B级术后4d死于肝衰。结论 SRHCC易于误诊，特别是既往“体健”者。SRHCC并非均为晚期病变，如有可能，早期肝癌破裂肝功能良好者应采取急症手术切除；如病人情况或医疗条件不允许，可行延期或二期手术治疗；对不能切除的晚期病人可采取保守治疗及其它治疗。     

胰腺钩突肿瘤的外科手术治疗(附10例报告)

目的 总结胰腺钩突肿瘤的临床特点及提高手术切除率的措施.方法 对10例胰腺钩突肿瘤行根治性手术治疗,其中7例联合PV、SMV切除,3例行经典的Whipple手术.7例联合血管切除术中,5例切除静脉干长度为2.0～4.2cm,直接对端吻合成功,2例行受浸润血管侧壁切除修补术.门脉阻断时间最长40min,最短8min,未同时阻断SMA.结果 联合PV、SMV切除的7例中,有1例术后3d肝功能衰竭死亡,1例未行脾静脉与SMV吻合者,术后出现大量乳糜样腹水,经治疗40d痊愈,术后存活20个月,余5例术后生存13～29个月.末联合静脉切除的3例中,2例分别存活13个月.14个月,1例已存活11.5个月至今健在,无癌肿复发.结论 胰腺钩突肿瘤具有缺乏早期症状和邻近血管早期受侵两个特点;门脉浸润不是根治手术禁忌证;联合PV、SMV切除4～5cm以内直接对端吻合是可行的.     

B超引导下 Mammotome旋切系统在乳腺微创外科中的应用研究(附320例报告)

目的探讨B超引导下Mammotome微创手术在乳腺病灶的诊断与治疗价值。方法我科2004年6月～2005年1月对320例患者511个乳腺病灶在B超引导下进行Mammotome微创切除术，并进行回顾性分析及评价其在乳腺微创外科的应用价值。结果术后病理学诊断7个乳腺浸润性导管癌，6个乳腺导管内癌，24个中度～重度不典型增生。474个为病理学诊断良性病变。13个乳腺癌患者及24个中度～重度不典型增生患者均接受后序开放性手术切除，没有发生组织学低估。所有病理诊断良性病变患者术后2个月～8个月均接受B超，均未发现手术残留乳腺病灶。结论应用B超引导下Mammotome旋切系统对3mm～30mm乳腺病灶可进行微创完整切除并能获得明确病理组织学诊断。     

联合门静脉切除的肝门部胆管癌根治切除术

目的观察联合门静脉切除在肝门部胆管癌治疗中的作用，以进一步提高肝门胆管癌的治疗效果。方法总结1990年3月至2002年3月我院收治的78例肝门部胆管癌的临床资料。结果本组联合门静脉切除12例，其中门静脉分又部联合左半肝切除3例，门静脉主干切除6例，门静脉侧壁切除修补术3例；术后肝肠吻合13漏、肝功能衰竭死亡1例；其余11例病人术后随访6个月至6年，平均19个月，其中最长的1例已存活6年。结论联合门静脉切除可提高肝门部胆管癌的治愈切除率，改善术后病人预后。     

血色病性肝硬化肝癌病人的外科治疗

目的 对卫生部北京医院3例血色病性肝硬化肝癌病人的外科治疗进行回顾性分析,探讨手术、射频消融、红细胞单采的治疗效果.方法 3例病人均为男性,术前诊断为血色病性肝硬化、肝癌.3例病人共进行8次外科治疗,包括手术切除、B超引导下经皮经肝肿瘤射频消融治疗.2例病人术后进行了希罗达化疗.3例病人均接受了红细胞单采治疗.结果 手术病理证实为肝细胞肝癌、肝硬化,普鲁士蓝染色阳性,诊断为血色病.3例病人术后平均存活86个月(39～154个月).结论 对血色病肝癌病人而言,最重要的是早期发现,肝移植或切除是首选治疗.对于再次复发的病人,采用包括射频消融、化疗、红细胞单采治疗等在内的综合治疗可以有效延长病人生存.     

中晚期肝癌的联合治疗

中晚期肝癌常伴有肝硬变及其他器官疾病，其治疗极为棘手。１９９０年８月至１９９３年６月，我们采用开腹肝动脉，或肝动脉左、右支栓塞结扎，术后在超声引导下行肝内门静脉化疗及肿瘤无水酒精注射联合治疗３２例中晚期肝癌。随访２～２４个月，死亡６例；１２例存活２～１０个月；１２例存活１０～２４个月；２例已超过２年。作者认为该方法具有操作简单、安全可靠及疗效确切等特点，是中晚期肝癌综合治疗中一种有效可行的方法。     

Selective regional chemotherapy of unresectable hepatic tumours using lipiodol.

Over a 30 month period from 1987 to 1990, selective hepatic cannulation under fluoroscopic control was performed in 57 consecutive patients with primary and secondary malignancies of the liver. Fifty-three patients were subsequently treated using intra-arterial Lipiodol emulsified with epirubicin. The tumours treated were hepatocellular carcinoma (n = 35), metastatic adenocarcinoma (n = 14), intrahepatic cholangiocarcinoma (n = 3) and leiomyosarcoma (n = 1). For hepatocellular carcinoma the cumulative survival was 38% at one year; the median survival was 12.2 months for Stage I, 6.3 months for Stage II and 0.9 months for Stage III tumours. In metastatic disease the cumulative survival was 63% at one year. These data suggest that targeted intra-arterial chemotherapy with Lipiodol-epirubicin is a useful palliative therapy for patients with Stage I and II HCC, and that a controlled trial of this treatment should be undertaken.     

Repeated Hepatic Dearterialization for Unresectable Carcinomas of the Liver: Report of a 10-Year Experience

The effectiveness of repeated hepatic dearterialization (RHD) therapy was evaluated in 26 patients with unresectable primary and secondary liver tumors. RHD was performed in 12 patients with hepatocellular carcinoma (HCC), 7 with hepatic metastases from colorectal carcinoma, and 7 with hepatic metastases from gastric carcinoma. It was repeatedly carried out by occluding the hepatic artery for 1 h twice daily. All patients concurrently received an intra-arterial infusion of anticancer drugs. More than 50% remission of the hepatic tumors, defined as a partial response (PR), was demonstrated in 8 patients (31%). A higher PR was seen in hepatic tumors from metastatic gastric cancer (5 out of 7 patients; 71%). Most patients who suffered severe complications had HCC with liver cirrhosis. These preliminary results suggest that RHD with intra-arterial chemotherapy is an acceptable palliative treatment for patients with unresectable liver metastasis from gastric cancer; however, the majority of patients with HCC are not responsive to such treatment, primarily because most have underlying cirrhosis predisposing to the development of postoperative complications at an unacceptably high rate. Received: August 24, 2000 / Accepted: May 15, 2001     

Early results with combined modality therapy for carcinoma of the esophagus.

Since January 1984, 74 patients (61 men, 13 women; age range: 43-76 years) with carcinoma of the esophagus were evaluated. Fifty-two patients had squamous cell carcinoma and 22 patients had adenocarcinoma. Sixty-three patients had preoperative chemotherapy and radiation that consisted of cis-platinum and VP-16 for squamous cell carcinoma and cis-platinum 5-FU for adenocarcinoma combined with 4500-6000 rads. Thirty-four patients were staged inoperable at the completion of the 4-month treatment regimen. Eleven patients had surgery alone because they refused or were not candidates for the preoperative regimen. Twenty-nine patients completed the combined modality regimen and have had esophagogastrostomy. All patients receiving chemotherapy and radiation demonstrated improved swallowing and a dramatic reduction of tumor mass early in the course of therapy and have been able to maintain oral nutrition without other support in the posttreatment period. Of the 34 patients who had chemotherapy and radiation therapy as palliation, 18 are currently living. One patient died secondary to complications of chemotherapy, another patient died at 9 months of myocardial infarction. The remaining patients died secondary to their disease. Of the 29 patients who had radiation therapy and chemotherapy plus esophagogastrostomy, 25 are alive. There were no operative deaths. One patient died at 9 months of stroke. Three other patients had recurrence and died 1 year after surgery. Of the 11 patients who had surgery alone, two have died of the disease. Of the 29 patients who completed the integrated therapy, 10 had no evidence of residual tumor in the specimen, and in an additional five patients only microscopic foci were evident. These early results are an encouragement to continue the multidiscipline approach to carcinoma of the esophagus in the hope that the quality of life and disease-free interval, as well as ultimate survival, will be enhanced.     

肝动脉、门静脉栓塞化疗治疗不可切除的原发性肝癌

目的：探讨肝动脉、门静脉双管栓塞化疗对不可切除的原发性肝癌的治疗作用。方法：对19例不可切除的原发性肝癌患者采用手术方法向肝动脉、门静脉植入皮下埋藏式投药泵,术中即开始经肝动脉投药泵栓塞化疗,术后7－10d在X线监测下经门静脉投药泵栓塞化疗,以后定期经两投药泵栓塞化疗,术后观AFP的变化、Bus或CT检查并与同期3次以上的32例HACE进行比较。结果：双栓化疗组17例术后1月AFP均下降、3月下降为正常8例,84．2％的肿瘤缩小,6月、9月、12月、24月生存率分别为89．5％、78．9％、68．4％、31．6％,中位生存期17．1月,其中2例进行了二期手术切除。HACE组术后1月AFP下降10例、3月后下降21例,46．9％的肿瘤缩小,6月、9月、12月、24月生存率分别为71．9％、53．1％、31．3％,中位生存期11．2月、12月、24月生存率组间比较P＜0．01;两组均无异位栓塞。结论：皮下埋藏式投药泵肝动脉、门静脉双插管栓塞化疗术后给药途径简单、方便、疗效好、并发症少,是治疗不可切除的肝癌有效方法之一。     

Chemotherapy-induced sclerosing cholangitis as a rare indication for resection: Report of a case

Bile duct stricture due to chemotherapy-induced sclerosing cholangitis (CISC) is a potentially fatal complication of hepatic arterial infusion chemotherapy (HAIC). It is managed primarily with medical treatment and biliary stenting. We report a rare case of a CISC-related biliary stricture requiring resection. The patient had been receiving adjuvant HAIC for 11 months after a curative liver resection for hepatocellular carcinoma, when clinically overt cholangitis developed. Radiologic and biopsy findings suggested a CISC-related biliary stricture limited to the common hepatic duct. We discontinued HAIC and started corticosteroid treatment, which finally became ineffective. Endoscopic biliary stenting was impossible because of her severe biliary sclerosis, necessitating resection of the stricture, which was confirmed histologically to be secondary sclerosing cholangitis. The patient has shown no signs of recurrent cholangitis for 12 postoperative months since her operation. Thus, resection could be a treatment option for a CISC-related biliary stricture in selected patients.     

Primary carcinoma of the liver.

Since 1947, 173 patients have been seen with primary carcinoma of the liver; 68 percent had hepatomas, 26 percent cholangiocarcinomas, and 6 percent mixed-cell carcinomas. Of these patients, 9 percent were Stage I or unstaged, whereas 28 percent were Stage III and had short lengths of survival. The 108 patients with Stage II carcinoma of the liver were analyzed according to treatment regimens. Thirty-one patients were observed but untreated; 47 patients were treated by systemic chemotherapy and 25 patients were treated by surgical resection. Three patients were treated by infusion chemotherapy and two by dearterialization. When primary carcinoma of the liver is resectable, approximately 20 percent of patients may be expected to become long-term survivors. If not resectable, short-term improvement in length of survival (8 to 13 months) may be obtained by systemic or infusion chemotherapy and by hepatic dearterialization. Earlier diagnosis and an aggressive surgical approach lends hope for some cures for patients with this difficult disease.     

Hepatic resection for disseminated germ cell carcinoma

Improvements in operative technique and perioperative management have expanded the application of hepatic resection for metastatic cancer. Although a policy of aggressive surgical resection of residual pulmonary and retroperitoneal disease following chemotherapy and normalization of serum tumor markers has been adopted for disseminated germ cell carcinoma, resection of residual hepatic disease in these cases has not been addressed. This report concerns a series of prospectively randomized patients who received systemic cisplatin-based chemotherapy for testis cancer during the past 13 years. Twenty-eight patients underwent resection of residual hepatic disease after serologic remission. Most (23 of 28 patients) of these procedures were performed concomitantly with other cytoreductive procedures. There were no operative deaths, although 28% of the patients developed complications. The 2-year survival rate was 54%, with an average follow-up of 34 months. Patients were stratified into three groups based on the most aggressive histology noted in the resected specimen. Survival is predicted by this histologic classification system. Hepatic resection can be performed safely and is an important component in the treatment of disseminated testicular carcinoma.     

Thirty years of experience with pediatric primary malignant liver tumors

Since 1950, 48 infants and children from 10 weeks to 16 years of age presented with primary hepatic malignancy. Signs and symptoms ranged from asymptomatic to those of malignant disease. All patients had a palpable abdominal mass. Jaundice was seen in five patients, four of whom had preexisting cirrhosis. Three male children had evidence of precocious puberty. Whereas liver function tests were usually normal, alpha-fetoprotein levels, when elevated, proved useful diagnostically and as a tumor marker in follow-up. Hepatic angiography and computed tomography (CT) scans have provided the most valuable preoperative assessment of hepatic architecture. Sixteen infants and children underwent resection for cure. Eleven of these patients are alive and disease free 6 months to 23 years later. Six additional patients had incomplete resection with subsequent radiotherapy and/or chemotherapy; only one such patient is disease-free past 3 years. Twenty-six tumors could only be biopsied; most of these patients died within 12 months regardless of what treatment they received. The histology was hepatoblastoma in 39 patients, hepatocellular carcinoma in 4, fibrolamellar carcinoma in 4, and malignant mesenchymal tumor (mesenchymoma) in 1. The patients with hepatocellular carcinoma and mesenchymoma all died. Three of four patients with fibrolamellar carcinoma are alive and disease-free following resection up to 3 years; this histology seems favorable. The other survivors had hepatoblastoma. The role of adjunctive chemotherapy and/or radiotherapy has not yet been determined.     

The treatments of hepatic metastasis from pancreato-biliary cancer

Hepatic metastases of pancreatobiliary cancer have a dismal patient prognosis of approximately 1 year after diagnosis. There have been a few reports in the literature on aggressive treatment of these patients with the intention of cure. For hepatic metastases from biliary cancer, hepatic resection has been performed in a small number of patients, resulting in a median survival time of less than 12 months. In our series of 7 patients, median survival time was 9 months. For hepatic metastases of gallbladder carcinoma, long-term (> 3-year) survivors have been reported. In our series of 16 patients, median survival time was 8 months, but one patient is still alive after more than 5 years. For simultaneous hepatic metastases of pancreas cancer. Howard et al and Takada et al have reported the results of aggressive surgical resection in 10 and 11 consecutive patients, respectively. The median survival times in their series were 11 and 6 months after hepatic resection and pancreaticoduodenectomy, respectively. These results cannot justify aggressive resection for patients with hepatic metastases of pancreatic cancer. In most series previously reported, the treatment for hepatic metastases from pancreatobiliary malignancies was systemic and regional chemotherapy, especially hepatic arterial infusion chemotherapy. However, there is no evidence suggesting a beneficial effect of cancer chemotherapy on prognosis. Therefore new therapeutic modalities should be developed to improve the outcome of the treatment of hepatic metastases of pancreatobiliary cancer.     

Arterial, portal, or systemic chemotherapy for patients with hepatic metastasis of colorectal carcinoma

Hepatic metastases from colorectal carcinoma are common and may be resected for cure. The response of liver metastases to systemic chemotherapy is low. In contrast, hepatic arterial chemotherapy produces higher response rates than systemic chemotherapy, but randomized trials have not definitely proved a survival advantage because they allowed cross over. Most adjuvant portal vein chemotherapy studies have shown a survival advantage over the control group, but it is not clear whether this benefit is from the portal vein therapy or from immediate postoperative chemotherapy, since there is rarely a reduction in liver metastases. We describe the results of systemic, hepatic artery infusion, and portal therapy for patients with liver metastases of colorectal carcinoma. Received for publication on Aug. 30, 1998; accepted on Nov. 2, 1998