转移性肝癌的介入治疗

目的探讨转移性肝癌的介入治疗方法及疗效。方法收集我院2004年8月至2008年4月介入治疗的62例转移性肝癌,其中胃肠道肿瘤肝转移40例,肺癌肝转移10例,胰腺癌肝转移4例,鼻咽癌肝转移3例,胆总管癌肝转移3例,膀胱癌肝转移1例,前列腺癌肝转移1例。62例中,病灶为富血供27例,中等血供15例,乏血供20例,对于病灶为富血供、中等血供者进行肝动脉化疗栓塞;乏血供病灶进行置管持续灌注化疗,导管保留1周,间隔3～4周,次。介入治疗后,分析其临床症状体征及生存期。结果介入治疗后,所有患者临床症状体征不同程度地减轻,未发生与操作有关的严重并发症,通过随访,生存率0．5a96．8％,1a61．3％,2a41．9％,3a12．9％。结论对于不能手术的转移性肝癌依其不同血供选择合适的介入治疗方式,可达到较好的临床效果。     

肝脏转移瘤影像学检查进展

肝转移癌的诊断是影像诊断的重要课题．肝转移病灶的及时检查发现对于寻找原发病灶、治疗方式的选择及预后的判断都有重要意义…。肝外原发恶性肿瘤向肝脏转移是癌细胞栓子从血液循环内到达肝动脉或门静脉内开始的．原发肿瘤的血供特点不是影响转移瘤强化方式和表现的唯一因素。结直肠癌、食管癌、胃癌、胰腺癌等消化道来源的肝转移瘤多为乏血供,而乳腺、肾脏、甲状腺等来源的转移瘤则为富血供。近年来的研究发现,肝动脉是肝转移瘤唯一的血供来源。影像学检查主要依据临床资料、肝脏转移瘤的血流动力学特点、代谢水平来判断其性质。     

Cox回归分析肝动脉化疗栓塞对大肠癌肝转移的疗效和预后的影响

目的 :分析TACE治疗大肠癌肝转移的疗效和影响预后的因素。方法:回顾性选取86例介入栓塞治疗后的大肠癌肝转移患者作为研究对象。利用Cox多元回归分析,判断TACE治疗大肠癌肝转移的疗效和影响预后的因素。结果:截止到随访结束日期,86例中,4例(4.7%)完全缓解(CR),40例(46.5%)部分缓解(PR),总有效率(CR+PR)为51.2%。所有患者在TACE治疗后,出现低热、右上腹胀痛、谷丙转氨酶轻度升高、消化道反应、骨髓抑制、食欲下降等,均可耐受。经过Cox多变量分析,富血供、高中分化者、无肝外转移者、大肠癌原发灶切除者、多次TACE治疗、碘化油沉积良好等为结直肠癌肝转移瘤TACE治疗的保护性因素,患者生存期延长。结论:TACE是治疗大肠癌肝转移有效的方法。肝转移瘤为富血供、高中分化者、无肝外转移者、大肠癌原发灶切除者、多次TACE治疗者、碘化油沉积良好等有利于提高患者的疗效和生存率。     

胃肠道肿瘤肝转移介入治疗的临床研究

目的：探讨胃肠道肿瘤肝转移数字减影血管造影术（DSA）表现和介入治疗效果。材料和方法：回顾分析61例胃癌、大肠癌肝转移瘤DSA表现和介入治疗方案，随访10个月-5年，评价其治疗效果和生存率。结果：胃癌、大肠癌肝转移的DSA表现可分为肿瘤边缘环状染色、较均匀染色和不染色3种，其中以边缘环状染色最常见。61例患者的有效率（CR＋PR）为86．7％，平均生存期为19．2个月，1年、3年、5年生存率分别为91．8％、32．8％、13．1％。结论：介入治疗是胃肠道肿瘤肝转移的有效治疗方法，正确地运用介入治疗技术，合理地使用化疗药物是提高疗效的关键。     

肝转移癌的DSA表现及介入性治疗

目的　研究肝转移癌ＤＳＡ表现及血管内介入治疗效果。材料和方法　５１例肝转移癌均行肝动脉造影,再行抗癌药物灌注或栓塞。结果　富血供型 ２０例（３９．２％）,等血供型 ９例（１７．７％）,乏协供型 ２２例（４３．１％）。肿瘤形态：结节状 ３３例;囊状４例;斑片状１４例。治疗后９２．２％病人症状减轻,５６．８％的肿瘤较前缩小,半年、１年、２年、３年存活率分别为９０．２％、５２．９％、２２．６％及１２．５％。结论　ＤＳＡ及其介入性治疗为肝转移瘤的一种有效的诊断和非手术治疗方法。     

膈下动脉供血在肝肿瘤介入治疗中的价值

目的：分析膈下动脉侧支形成原因和膈下动脉供血病灶的分布范围，探讨膈下动脉供血在肝癌介入化疗加碘油栓塞（TACE）术中的价值。资料与方法：膈下动脉供血的肝癌21例，男16例，女5例，年龄41－67岁，平均58岁，其中原发性肝癌17例，结肠癌肝转移3例，乳腺癌肝转移1例，术前行CT或MRI平扫及增强扫描，术中发现膈下动脉供血后，行膈下动脉造影，在确认供血范围后将导管超选择至供血支，灌注化疗药，注入碘油，明胶海绵栓塞血管，并摄肝内碘油平片。结果：膈下动脉造显示接受膈下动脉供血的肝内病灶沿膈下动脉走行分布，供血以右膈下动脉为主，病灶多发，多数与其他动脉支同时供养肿瘤组织，注入碘油后，病灶内碘油沉积良好，结论：膈下动脉是供养肝肿瘤的重要侧支血管，原发于肝动脉的供血支闭塞是促其形成的主要原因，在肝癌介入治疗中具有重要意义。     

肝动脉解剖变异及多支供血在肝癌介入治疗中的临床意义

目的：研究肝动脉解剖变异和肝癌多支供血及临床意义。材料和方法：140例肝癌行介入治疗前常规腹腔动脉和肠系膜上动脉造影，邻近膈肌病灶加作选择性膈下动脉造影，分析造影图象。结果：肝动脉常见型113例（80．8％），变异27例（19．2％）。病灶单纯由肝动脉供血92例，48例存在除肝动脉外的多支血管供血。结论：熟悉肝癌的血供特点可指导术者方便快捷插入导管，发现除肝动脉外的供血动脉，并给予化疗栓塞以确保疗效。     

胃肠道肿瘤肝转移血管内介入治疗效果分析

目的：探讨多次动脉化疗栓塞术(TACE)治疗胃肠道肿瘤肝转移的效果。方法：43例胃肠道肿瘤肝转移患者行肝动脉化疗栓塞术。均于第三次治疗后2—4个月复查，观察瘤灶反应。结果：本组病例中完全缓解7．0％(3／43)，部分缓解44．2％(19／43)，无变化25．6％(11／43)，进展23．3％(10／43)，有效率51．2％(22／43)。6个月、12个月、2年生存率分别为92．6％、70．4％、14．8％。结论：动脉化疗栓塞法治疗胃肠道肿瘤肝转移有确切疗效，对于乏血供转移灶亦有良好效果。     

贲门癌肝转移的血供特点及其与经动脉化疗栓塞疗效的相关性

目的探讨贲门癌肝转移的血供特点及其与经动脉化疗栓塞治疗效果的关系。方法对42例经临床和病理组织学证实的贲门癌肝转移患者同时行贲门及肝脏肿瘤靶动脉栓塞化疗术。随后,在所有患者中观察了病灶血供特点,并评价了经动脉化疗栓塞治疗的效果及生存率。结果贲门癌病灶主要由胃左动脉供血,左膈下动脉、胃右动脉及肝左动脉可能参与供血。肝转移瘤由肝动脉供血,其中富血供、染色征明显者6例(14.3%),治疗有效率为83.3%;血供中等、染色较淡28例(66.7%),治疗有效率为53.5%;血供稀少、染色呈淡絮状或无明显染色8例(19.0%),治疗有效率为37.5%。经动脉化疗栓塞术后,0.5、1、2、3、5a生存率分别为90.4%,76.1%,33.3%,7.1%和2.4%。本组患者于诊断后中位生存期为19.6个月。结论经动脉化疗栓塞治疗是贲门癌肝转移的有效治疗方法,富血供肿瘤疗效优于乏血供肿瘤。     

肝癌介入治疗后患者预后因素的Cox回归模型分析

目的：综合评价各预后因素对接受介入治疗的原发性肝癌患者生存期的影响。材料和方法：对３０８例中、晚期肝癌介入治疗后得到密切随访患者的预后因素进行了Ｃｏｘ回归模型分析。结果：总体１、２、３、４年的生存率分别是５４．５５％、３５．２３％，２２．５６％、９．８４％。单因素分析显示有意义的预后因素是临床分期、肿瘤大小、肝动脉化疗栓塞（ＨＡＥ）次数、门脉癌栓、淋巴细胞转化率；多因素分析为：ＨＡＥ次数、肿瘤大小、肝动脉灌注化疗（ＨＡＩ）次数、性别、淋巴细胞转化率。结论：单纯ＨＡＩ无明显治疗价值，但与ＨＡＥ联合运用则有显著意义；辅以保护和提高机体免疫的综合治疗可进一步提高疗效；对有门脉癌栓患者宜采取更积极的治疗态度     

Radiofrequency ablation of colorectal liver metastases: long-term survival

PURPOSE: To evaluate the results of radiofrequency ablation (RFA) therapy with regard to long-term survival and rate of complications in patients with liver metastases from colorectal carcinoma. MATERIAL AND METHODS: A total of 102 patients were included and treated with RFA. In 100 patients, resection was not possible; two patients refused surgery. The patients had a total of 332 colorectal liver metastases. Pre- and post-treatment evaluation was performed with contrast-enhanced computed tomography. Survival from time of diagnosis of liver metastases was calculated by Kaplan-Meier analysis. Complications were recorded as minor or major in accordance with the definitions of the Society for Cardiovascular and Interventional Radiology. RESULTS: Estimated median survival from time of diagnosis of liver metastases was 52 months (95% CI 34-82). Estimated 1-, 2-, 3-, 4-, and 5-year survival was 96%, 79%, 64%, 52%, and 44%, respectively. Minor complications were recorded following seven RFA treatments (4.0%) and major complications following 12 RFA treatments (6.9%). CONCLUSION: RFA is an effective method to treat liver metastases from colorectal carcinoma. Survival is improved and comparable with survival following surgical resection. The rate of complications is low.     

Colorectal carcinoma metastases in liver: laser-induced interstitial thermotherapy--local tumor control rate and survival data

PURPOSE: To evaluate the local tumor control and survival data for magnetic resonance (MR) imaging-guided laser-induced interstitial thermotherapy (LITT) of colorectal liver metastases. MATERIALS AND METHODS: MR imaging-guided LITT was performed in 603 patients (mean age, 61.2 years) with 1,801 liver metastases of colorectal cancer. Survival rates were calculated by means of the Kaplan-Meier method. Local tumor control and tumor volume were evaluated with nonenhanced and contrast material-enhanced MR imaging. Indications for the procedure were defined for patients with five or fewer metastases, none of which were larger than 5 cm in diameter. The indications included recurrent liver metastases after partial liver resection in 37.6% of study patients, metastases in both liver lobes in 32.5%, locally nonresectable lesions in 11.3%, general contraindications for surgery in 4.6%, and refusal to undergo surgical resection in 13.9%. RESULTS: Local recurrence rate at 6-month follow-up was 1.9% (nine of 474) for metastases up to 2 cm in diameter, 2.4% (13 of 539) for metastases 2.1-3.0 cm in diameter, 1.2% (four of 327) for metastases 3.1-4.0 cm in diameter, and 4.4% (13 of 294) for metastases larger than 4 cm in diameter. The mean survival rate for all treated patients, with calculation started on the date of diagnosis of the metastases (which were treated with LITT) was 4.4 years (95% CI: 4.0, 4.8) (1-year survival, 94%; 2-year survival, 77%; 3-year survival, 56%; 5-year survival, 37%). Median survival was 3.5 years (95% CI: 3.0, 3.9). Mean survival after the first LITT treatment was 3.8 years (95% CI: 3.4, 4.2). Median survival was 2.9 years (95% CI: 2.4, 3.3). CONCLUSION: MR imaging-guided LITT yields high local tumor control and survival rates in well-selected patients with limited liver metastases of colorectal carcinoma.     

结直肠癌肝转移瘤的CT动态增强强化特点及病灶分布规律

目的：探讨结直肠癌肝转移瘤的 CT 动态增强强化特点和病灶分布规律。方法：回顾性分析120例结直肠癌肝转移瘤患者的 CT 动态增强图像及临床资料,记录肿瘤原发灶部位、肝转移瘤的位置和数目、肝转移瘤的不同时相的强化特点及肠系膜下静脉汇入门静脉的位置。结果：CT 动态增强共检出肝内病灶486个,其中表现为环状强化灶245个（50．4％）,结节状强化灶183个（37．7％）,其他不典型强化灶58个（11．9％）。原发病灶位于右半结肠（右半结肠组）时,其转移灶在肝左、右叶的分布差异有统计学意义（P ＜0．05）。原发病灶位于左半结肠（左半结肠组）时,其转移灶在肝左、右叶的分布差异无统计义（P ＞0．05）。排除转移灶均匀分布于肝左、右叶的病例后,右半结肠组与左半结肠组肝转移灶的分布差异无统计学意义（P ＞0．05）。左半大肠癌肝转移患者中,肠系膜下静脉（IMV）汇入脾静脉（SPV）者34例,其转移灶在肝左、右叶的分布差异有统计学意义（P ＜0．05）。IMV 汇入肠系膜上静脉（SMV）者32例,其转移灶在肝左、右叶的分布差异有统计学意义（P ＜0．05）。IMV 汇入 SPV 与 SMV 汇合处者11例,其转移灶在肝左、右叶的分布差异无统计学意义（P ＞0．05）。结论：结直肠癌肝转移瘤的 CT 动态增强图像有一定特点,结直肠癌肝转移瘤的病灶分布有一定规律,了解这些情况有助于提高结直肠癌肝转移瘤的检出率和诊断符合率,减少误诊率。     

Metastasen des kolorektalen Karzinoms

Metastases of colorectal cancer represent an interdisciplinary therapeutic challenge. Evidence-based guidelines are supportive of treatment decisions in specific situations with the objective to improve the therapeutic outcome for patients. Interventional tumor therapies are increasingly applied therapeutic options in the treatment of colorectal metastases. The current literature indicates that thermoablation of colorectal liver metastasis can lead to an improved survival in selected patients. However, recommendation of thermoablation as a part of guidelines for the therapy of colorectal metastases is restricted due to a shortcoming of randomized controlled trials. Therefore, interventional tumor therapies have to be evaluated in comparison with standard therapies, particularly with regard to surgical resection and chemotherapy. Moreover, the interdisciplinary combination of tumor ablation, surgical resection, and chemotherapy is a promising approach for the optimization of oncological therapy strategies in the treatment of colorectal metastases.     

Radiofrequency ablation for colorectal liver metastases: prognostic factors in non-surgical candidates

Purpose

To determine prognostic factors in patients with colorectal liver metastases who were not surgical candidates and received liver radiofrequency (RF) ablation.

Materials and methods

RF ablation was done for 141 colorectal liver metastases in 84 patients. There were 63 (75.0?%, 63/84) males and 21 (25.0?%, 21/84) females, with a mean age of 64.6?±?10.3. The mean maximum tumor diameter was 2.3?±?1.4?cm (range 0.5?C9.0?cm). Extrahepatic metastases were associated at the time of liver RF ablation in 23 patients (27.4?%, 23/84), and 12 (14.3?%, 12/84) had lung metastases considered controllable by planned lung RF ablation. Prognostic factors were evaluated by univariate and multivariate analyses.

Results

There was no procedure-related mortality. The 1-, 3-, and 5-year overall survival rates were 90.6?% (95?%CI, 83.9?C97.2?%), 44.9?% (95?%CI, 31.8?C57.9?%), and 20.8?% (95?%CI, 7.3?C34.3?%), respectively, with a median survival of 34.9?months. The univariate analysis showed that tumor diameter larger than 3?cm, tumor multiplicity, uncontrollable extrahepatic disease, and previous chemotherapy history were significantly worse prognostic factors. The former three factors remained significant for worse prognosis in the multivariate Cox model. Extrahepatic disease was not a prognostic factor when it could be controlled.

Conclusion

Tumor size and number, and uncontrollable extrahepatic metastases were significant prognostic factors.     

The role of F-18 FDG positron emission tomography in preoperative assessment of the liver in patients being considered for curative resection of hepatic metastases from colorectal cancer

PURPOSE: The authors' goal was to determine the sensitivity and specificity of F-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) for identifying patients with hepatic metastases from colorectal cancer and the accuracy of PET for determining the number and distribution of lesions within the liver. Intraoperative sonography and surgical inspection and palpation were used as the reference standard. METHODS: Twenty-three patients being evaluated for surgical resection of hepatic metastases from colorectal carcinoma underwent FDG PET before operation. Findings of the PET studies were reviewed in a blinded, retrospective manner, with the results compared with the findings of intraoperative sonography and surgical exploration. Lesions of all sizes were considered in the analysis. RESULTS: The FDG-PET results were positive in 21 of the 22 patients ultimately found to have metastatic disease to the liver, and they were negative in the single patient without metastases. Therefore, for identification of patients with hepatic metastatic disease, PET has a sensitivity of 95% and a specificity of 100%. In all, 48 metastatic lesions were identified in these patients, of which 38 (79%) were identified on PET images. The probability of lesion detection by PET was directly correlated with lesion size (P < 0.01). The assessment of lobar disease distribution in the liver was discordant between PET and surgery in 3 of 23 (13%) patients. CONCLUSIONS: In patients being evaluated for potential curative resection of hepatic metastases from colorectal cancer, FDG PET is accurate for the identification of the presence or absence of metastatic disease to the liver. However, detection of individual lesions depends on their size, and determination of lesion number and distribution within the liver is more accurately accomplished with intraoperative sonography.     

Survival after Radiofrequency Ablation in 122 Patients with Inoperable Colorectal Lung Metastases

Purpose

To analyze the factors associated with favorable survival in patients with inoperable colorectal lung metastases treated with percutaneous image-guided radiofrequency ablation.

Methods

Between 2002 and 2011, a total of 398 metastases were ablated in 122 patients (87 male, median age 68 years, range 29–90 years) at 256 procedures. Percutaneous CT-guided cool-tip radiofrequency ablation was performed under sedation/general anesthesia. Maximum tumor size, number of tumors ablated, number of procedures, concurrent/prior liver ablation, previous liver or lung resection, systemic chemotherapy, disease-free interval from primary resection to lung metastasis, and survival from first ablation were recorded prospectively. Kaplan–Meier analysis was performed, and factors were compared by log rank test.

Results

The initial number of metastases ablated was 2.3 (range 1–8); the total number was 3.3 (range 1–15). The maximum tumor diameter was 1.7 (range 0.5–4) cm, and the number of procedures was 2 (range 1–10). The major complication rate was 3.9 %. Overall median and 3-year survival rate were 41 months and 57 %. Survival was better in patients with smaller tumors—a median of 51 months, with 3-year survival of 64 % for tumors 2 cm or smaller versus 31 months and 44 % for tumors 2.1–4 cm (p = 0.08). The number of metastases ablated and whether the tumors were unilateral or bilateral did not affect survival. The presence of treated liver metastases, systemic chemotherapy, or prior lung resection did not affect survival.

Conclusion

Three-year survival of 57 % in patients with inoperable colorectal lung metastases is better than would be expected with chemotherapy alone. Patients with inoperable but small-volume colorectal lung metastases should be referred for ablation.     

磁共振扩散加权成像对结肠癌术后肝转移灶检出的临床研究

目的:探讨磁共振扩散加权成像对结直肠癌肝转移的诊断价值。方法:27例结直肠癌患者行肝脏磁共振扩散加权成像、非增强磁共振和多层CT检查。阅片前告知阅片者患者为结直肠癌术后,但不提供临床病史和既往影像学资料。结果:多层CT、非增强磁共振和扩散加权成像对肝转移灶的敏感度分别为72%(45/63)、76%(48/63)和93%(58/63),扩散加权成像对肝转移灶具有更高的敏感度且与多层CT和非增强MRI相比,差异有显著性意义。扩散加权成像对肝转移患者敏感度最高(82%),而多层CT和非增强MRI分别为77%和66%。结论:磁共振扩散加权成像对结直肠癌肝转移灶的检出率高于多层CT和非增强MRI。     

Recursive Partitioning Analysis (RPA) Class Does Not Predict Survival in Patients with Four or More Brain Metastases

BACKGROUND: We evaluated prognostic factors for survival in patients with four or more brain metastases in order to determine whether intense local treatment might be justified for some of them. If up to three brain metastases are present, surgical resection or radiosurgery are currently being considered in case of favorable prognostic factors. PATIENTS AND METHODS: Retrospective intention-to-treat analysis of 113 patients who underwent whole-brain radiotherapy without surgical resection or radiosurgery at a single institution. Standard treatment was given with ten fractions of 3 Gy. Higher total doses were administered in 13% of patients. Recursive partitioning analysis (RPA) prognostic classes have been described by the Radiation Therapy Oncology Group (RTOG) in 1997 (class I: Karnofsky performance status [KPS] > or = 70%, age < or = 65 years, no extracranial metastases, controlled primary tumor; class III: KPS < 70%; class II: others). RESULTS: Median number of brain metastases was six (four to 50). Most patients (69%) had extracranial metastases as well. Criteria of RPA Class I (II) were met in 4% (41%), whereas 56% had KPS < 70% and thus were grouped into class III (Tables 1 and 2). Complete or partial remission of brain metastases was found in 46% of patients who underwent computed tomography. Median survival was 4 months, 1-years survival rate 15%. Only age was a borderline significant prognostic factor in univariate analysis (< or = 50 years vs > 50 years, p = 0.05). Strong trends were found for KPS, extracranial metastases, control of the primary tumor, and breast primary tumor. Number of brain metastases, RPA class and treatment-related factors such as total dose or remission of brain metastases had no appreciable influence on survival (Figure 1). Multivariate analysis failed to identify any significant prognostic factor. CONCLUSIONS: Patients with four or more brain metastases seem to represent a group with unfavorable prognosis where remission of brain metastases or administration of more than 30 Gy were not associated with increased survival. The number of patients in RPA class I was too small to draw final conclusions. However, there was absolutely no survival difference between patients in class II (median survival 3.6 months) and III (median 4.2 months).