肝细胞癌合并胆管癌栓多学科诊治中国专家共识（2020版）

肝细胞癌(hepatocellular carcinoma,HCC;以下简称肝癌)发病率位居全世界常见恶性肿瘤第六位,每年新发病例约74万,近一半在中国。在我国,肝癌相关死亡率仅次于肺癌和胃癌,高居第三位[1-2]。临床上,肝癌多侵犯血管形成血管癌栓,亦可侵犯胆管形成胆管癌栓(bile ducttumor thrombus,BDTT)。文献[3-5]报道,BDTT发生率为0.5%~2.5%。BDTT可沿肝内胆管向肝门部胆管延伸,甚至阻塞胆总管导致黄疸、胆道出血等。其自然病程约为1~3个月[6-7]。     

肝细胞癌合并胆管癌栓多学科诊治中国专家共识(2020版)

肝细胞癌合并胆管癌栓是肝癌的一种特殊类型,发生率为0.5%~2.5%,疾病进展快、预后差,目前国内外尚无相关的诊断与治疗共识,造成该疾病的治疗极不规范。中国医师协会肝癌专业委员会基于国内外本领域研究获得的循证医学证据,并结合我国临床实践,制订《肝细胞癌合并胆管癌栓多学科诊治中国专家共识(2020版)》。该共识针对肝细胞癌合并胆管癌栓的临床表现、诊断及分型、外科治疗、辅助治疗以及其他局部、区域性和系统性治疗进行系统阐述,旨在规范、普及和提高对肝细胞癌合并胆管癌栓的诊断和多学科治疗水平,改善该疾病总体预后。     

Functional paraganglioma with tumor thrombus in the inferior vena cava,first case report

Pheochromocytoma (PHEO) is a rare neuroendocrine that tumor originated from the adrenal medulla that secrets catecholamines. Tumors from extra-adrenal chromaffin tissues are called extra-adrenal PHEO or paraganglioma (PGL). To our knowledge, adrenal PHEO and subclinical PGL with inferior vena cava (IVC) invasion had been sporadically reported, while functional PGL with IVC tumor thrombus has not been publicly reported yet. Perioperative management of those diseases is less well established because of their multidisciplinary nature and rarity. We herein present a case of primary malignant PGL with IVC invasion. A 16-year-old female patient with a history of severe paroxysmal hypertension was admitted to Peking Union Medical College Hospital on suspicion of retroperitoneal mass. In-house diagnostic work-up revealed a malignant PGL with IVC invasion, inferior mesenteric artery encasement and, aorta engagement. Multi-disciplinary discussions were held and careful preoperative preparation plans were made. After everything was ready, the functional PGL and tumor thrombus were completely resected, then a reconstruction of IVC was performed. The patient was discharged on postoperative day 14 and all her clinical symptoms disappeared afterward. No evidence of tumor residual or metastasis was found in the subsequent six months of follow-up. Gene tests were made for her and her family. Albeit its rarity, functional PGL with IVC invasion is not unresectable, a multi-disciplinary task force should be established to settle down every detail. We recommended 3-dimensional imaging reconstruction for gaining a better anatomic understanding. Literature reviews showed that complete resection is the premise of a good prognosis. In particular cases, complementary or alternative therapy like chemotherapy and ¹³¹I-metaiodobenzylguanidine might help, family hereditary genetic tests are advised as well.     

Liver transplantation: would it be the best and last chance of cure for hepatocellular carcinoma with major venous invasion?

BackgroundHepatocellular carcinoma (HCC) with portal vein tumour thrombus (PVTT) signifies advanced disease, whether LT confers any survival superiority over resection remains uncertain.MethodsA propensity score matched (PSM) analysis of liver transplantation (LT) and liver resection (LR) for HCC with PVTT was performed.ResultsA consecutive series of 88 patients who received either LT (10 DDLTs and 3 LDLTs) or LR (n=75) respectively were recruited. Before PSM, the LT group has a higher MELD score (17.3 vs. 7.8, P<0.001), lower serum AFP levels (96 vs. 2,164 ng/mL, P=0.017) and smaller tumour size (4 vs. 10 cm, P<0.001). The 5-year overall survival for LT and LR were 55.4% and 15.9% respectively (P=0.007). After matching for serum AFP levels and tumour size, 1-, 3- and 5-year overall survival for LT were 81 ng/mL, 3.9 cm, 80%, 70% and 70% and the corresponding rates for LR were 1,417 ng/mL, 5.3 cm, 51.8%, 19,6% and 9.8% (P value =0.12, 0.27 and 0.009 respectively).ConclusionsLT is associated with significantly better oncological outcomes in HCC patients with PVTT involving the lobar or segmental level. A modest expansion of selection criteria to include small HCC with segmental PVTT should be considered.     

竹节人参提取物抗脑缺血作用的实验研究

目的 为探讨竹节人参提取物的脑保护机制,观察竹节人参提取物对血栓形成和缺血性脑水肿的作用。方法 结扎小鼠带迷走神经的两侧颈总动脉造成急性脑缺血,结扎大鼠双侧颈总动脉造成急性不宛性脑缺血,实验性造成大鼠体内血栓形成,观察生节人参对它们的影响。结果 竹节人参提取物明显延长小鼠缺氧存活时间,明显延长小鼠因结扎带迷走神经的两侧颈总动脉造成急性脑缺血的存活时间,能减轻大鼠实验性血栓的湿重和干重,显著降低大鼠     

多平面经食管超声心动图对心瓣膜病合并心内血栓的诊断价值

目的：探讨多平面经食管超声心动图对心瓣膜病合并心内血栓的诊断价值。方法：分别５３例心瓣膜病合并心内血栓的多平面经食管超声心动图（ＭＴＥＥ）和经胸超声心动图（ＴＴＥ）技术的声像图表现。结果：ＭＴＥＥ及ＴＴＥ对心内血栓检出率分别１００％及６９．８％;ＭＴＥＥ能检出云雾状、血液淤滞和絮状新鲜血栓,而ＴＴＥ则无法显示这些声像图。结论：ＭＴＥＥ对心内血栓的检出率高,临床应用ＭＴＥＥ检查心瓣膜病,对选择治疗措     

Acute clinical deterioration in a patient with end-stage dilated cardiomyopathy and left ventricular thrombus formation

The case of a 17-year-old male patient with severe end-stage dilated cardiomyopathy and a large thrombus formation within the cavum of the left ventricle is reported. After an acute thrombectomia combined with a partial left ventriculectomy (Batista procedure), the patient was successfully treated with an appropriate left ventricular assist device (LVAD) system using a centrifugal nonocclusive pump (Biomedicus, Medtronic, Anaheim, CA, U.S.A.). Mechanical support was removed on Day 9, and the patient was discharged from the hospital on Day 19. The effectiveness of emergency mechanical support in patients with very unfavorable prognoses is discussed.     

Left Ventricular Thrombus After Pregnancy: Choice of Surgical Access Using Dynamic Three-Dimensional Echocardiography

Two idiopathic thrombi loosely attached to the left ventricular wall were detected by dynamic three-dimensional echocardiography. Because the thrombi were shown to be lobulated and extremly mobile, urgent surgical treatment was mandatory. Three-dimensional image reconstruction enhanced appreciation of left ventricular thrombi by enabling accurate imaging of the spatial relationship between the thrombus, the myocardial wall, and the valvular apparatus, so that the most advantageous surgical access could be chosen.     

Microembolization from a carotid mural thrombus detected by transcranial Doppler

Over the last few years, many authors have described the possibility of using transcranial Doppler to demonstrate the passage of microemboli in the cerebral arteries. We report the case of a 44-year-old woman with thrombotic diathesis and thrombocytosis who was admitted twice within a short period of time (one and a half months) to a neurological department because of multiple cerebral infarctions. On the occasion of the second admission, a colour-Doppler examination of the epiaortic vessels, which had previously been negative, showed a carotid lesion due to a mural thrombus and, on the same side as the carotid lesion, transcranial Doppler detected short-duration, high-intensity signals in the middle and anterior cerebral arteries, an expression of the passage of microemboli.As already described by other authors in similar clinical situations, our case confirms that transcranial Doppler can identify the passage of microemboli in the circle of Willis.

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Sommario Negli ultimi anni è stata descritta da molti autori la possibilità di dimostrare mediante Doppler transcranico il passaggio di microemboli nelle arterie cerebrali. Riportiamo il caso di una donna di 44 anni con diatesi trombotica e trombocitosi ricoverata per due volte, a breve distanza di tempo (un mese e mezzo), in ambiente neurologico per infarti cerebrali multipli. In occasione del secondo ricovero l'esame Color-Doppler dei vasi epiaortici, che era risultato negativo in precedenza, ha evidenziato una lesione carotidea riferibile a un trombo murale e al Doppler transcranico sono stati rilevati, omolateralmente alla lesione carotidea, segnali di breve durata ed alta intensità nelle arterie cerebrali media e anteriore, espressione di passaggio di microemboli.Come già descritto da alcuni autori in situazioni cliniche simili, il nostro caso conferma la possibilità di individuare, mediante Doppler transcranico, il passaggio di microemboli nel circolo cerebrale.

     

Left atrial thrombi in non-rheumatic atrial fibrillation: assessment of prevalence by transesophageal echocardiography

To determine the prevalence of left atrial thrombus in hospitalized patients with non-rheumatic atrial fibrillation, 48 patients were consecutively studied with single-plane transesophageal echocardiography. There were 23 males (48%) and 25 females (52%). The mean age was 66±11 years (range 43–87). Thrombus was detected in 13 patients (27%) 11 were confined to the left atrial appendage, 1 to the atrial body and appendage, and 1 to the left upper pulmonary vein. Prevalence of atrial thrombus was not different among those patients with or without previous stroke [4/16 (25%) vs 9/32 (28%), p=NS] or between patients > 65 years and patients 65 years old (p=NS). Atrial thrombus was detected more frequently in patients with reduced left ventricular global systolic function than in those with normal function [7/14 (50%) vs 6/34 (17%), p<0.05]. In patients with spontaneous contrast echoes in the left atrium, thrombi were visualized more often than in those without spontaneous echoes [10/24 (41%) vs 3/24 (12%), p<0.05]. The finding of the atrial spontaneous contrast echoes was more frequent among patients with reduced left ventricular global systolic function [11/14 (78%) vs 13/34 (37%), p<0.02].We conclude that in hospitalized patients with non-rheumatic atrial fibrillation the prevalence of left atrial thrombus is high. Reduced left ventricular global systolic function identifies a subset of patients at high risk for formation of thrombus in the left atrium.