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。     

肝细胞癌合并肝静脉或下腔静脉癌栓多学科诊治中国专家共识（2019版）

肝细胞癌(以下简称肝癌)是世界第六大常见癌症,每年约有74万新发病例,其中一半发生在中国,在我国肝癌相关病死率仅次于肺癌,高居第三位[1-2]。临床上肝癌多侵犯门静脉而形成门静脉癌栓(portal vein tumor thrombus,PVTT),其亦可侵犯流出道形成肝静脉癌栓(hepatic vein tumor thrombus,HVTT)、下腔静脉癌栓(inferior vena cava lunior thrombus,1VCTT)甚至右心房癌检(right atrium tumor thrombus,RATT),其发生率为1.4%~4.9%[3-6]。肝癌合并HVTT/IVCTT病人预后极差,多在短时间内出现肝功能衰竭或癌栓脱落死于肺栓塞、心脏填塞等,若不进行治疗,病人中位生存时间仅为3个月[7-8]。     

《肝细胞癌合并肝静脉或下腔静脉癌栓多学科诊治中国专家共识(2019版)》解读

肝细胞癌合并肝静脉或下腔静脉癌栓(HVTT/IVCTT)是肝癌的一种特殊类型,发生率为1.4％～4.9％,疾病进展快、预后差.中国医师协会肝癌专业委员会基于国内外HVTT/IVCTT相关研究获得的循证医学证据,并结合我国的临床实践,制订了《肝细胞癌合并肝静脉或下腔静脉癌栓多学科诊治中国专家共识(2019版)》.该共识针...     

肝细胞癌合并胆管癌栓的外科治疗进展

肝细胞癌伴胆管癌栓临床少见,肝炎、肝硬化病史、甲胎蛋白的升高以及肝癌的特征性影像学表现是其诊断的主要依据。但术前漏诊、误诊率高,误诊原因多是片面强调影像学检查结果,忽视了对临床资料的综合分析。肝细胞癌合并胆管癌栓并非晚期表现,胆管癌栓并没有增加手术的风险,也没有明显降低术后存活率,因此对肝细胞癌合并胆管癌栓行合理术式是一种积极有效的治疗方法。肝移植作为一种极端的手术方式值得探讨。     

《肝细胞癌合并门静脉癌栓多学科诊治中国专家共识（2016年版）》解读

肝癌细胞容易侵犯肝内的脉管系统尤其是门静脉系统,形成门静脉癌栓（PVTT）,一旦出现PVTT,病情发展迅速,提示预后不良。基于现有的循证医学证据,尤其是国内学者对肝细胞癌合并PVTT的研究结果,全国肝癌合并癌栓诊治研究协作组制定了《肝细胞癌合并门静脉癌栓多学科诊治中国专家共识（2016年版）》。笔者从PVTT分型及不同类型癌栓治疗方式选择等角度对共识进行了解读。

     

肝细胞癌并胆管癌栓

肝细胞癌是最常见的恶性肿瘤之一。肝癌的外科治疗在其综合治疗中占重要地位。关于肝细胞癌血管的侵犯 ,尤其是侵犯门静脉形成血管栓子已有较多报道。文献记载肝细胞癌患者约34%～ 4 0 %有门静脉癌栓 (ｐｖｔｔ) [1、2 ] 。胆管癌栓的出现率低 ,约 1.6 %～3% [3、4] ,报道文献很少。但因胆管癌栓而出现黄疸、被认为病程较晚的肝细胞癌患者 ,若经积极处理 ,仍可获得较好的预后。现对肝细胞癌并胆管癌栓病例综述如下。一、肝细胞癌并胆管癌栓的诊断根据胆管癌栓所在部位 ,患者的临床表现不一。有的病例会出现梗阻性黄疸的表现 ,而有的患者则无…     

基于免疫节点抑制剂的肝细胞癌免疫联合治疗多学科中国专家共识（2021版）

基于免疫节点抑制剂（ICIs）的肝癌免疫联合治疗在临床研究和临床实践中已取得了显著的疗效,但在临床推广普及的过程中也发现了许多亟待解决的问题。通过多学科专家的共同研讨,《基于免疫节点抑制剂的HCC免疫联合治疗多学科中国专家共识（2021版）》主要聚焦于ICIs疗法临床应用的原则与方法,包括适应证选择、药物处方、治疗方式...     

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目的探讨肝细胞癌(HCC)合并胆管癌栓外科治疗的效果。方法对1984年7月至2002年12月收治的53例HCC合并胆管癌栓的治疗情况进行回顾性总结和分析。结果53例中，1例未治，6例行经皮肝穿刺胆道引流(PTCD)，46例开腹手术。开腹手术术后30d病死率为13．0％，并发症发生率为32．6％。肝切除术、胆管取癌栓及胆道引流术病人术后生存时间为5～46个月，中位生存期为23．5个月。结论黄疸不一定是肝癌的晚期表现，也不一定是手术禁忌证，对HCC合并胆管癌栓的早期诊断和手术治疗，是改善病人预后的关键。     

The benefit of curative liver resection with a selective bile duct preserving approach for hepatocellular carcinoma with macroscopic bile duct tumor thrombus

BackgroundHepatocellular carcinoma (HCC) presenting with macroscopic bile duct tumor thrombus (BDTT) is an uncommon event. The role of a curative hepatic resection and associated long-term outcomes remain controversial. In addition the necessity for bile duct resection is still unclear. The aim of this study was to evaluate outcomes of hepatectomy with a selective bile duct preservation approach for HCC with BDTT in comparison to outcomes without BDTT.MethodsA total of 22 HCC with BDTT patients who had undergone curative hepatic resection with a selective bile duct preservation approach at our institute were retrospectively reviewed. These were compared to group of 145 HCC without BDTT patients. The impact of curative surgical resection and BDTT on clinical outcomes and survival after surgical resection were analyzed.ResultsAll HCC with BDTT cases underwent major hepatectomy vs. 32.4% in the comparative group. Bile duct preservation rate was 56.5%. The 1-, 3- and 5-year survival rates of HCC with BDTT patients in comparison to the HCC without BDTT group were 81.8%, 52.8% and 52.8% vs. 73.6%, 55.6% and 40.7% (P=0.804) respectively. Positive resection margin, tumor size ≥5 cm and AFP ≥200 IU/mL were significant risk factors regarding overall survival. However, it is unclear whether presence of a bile duct tumor thrombus has an adverse impact on either recurrence free survival or overall survival.ConclusionsBile duct obstruction from tumor thrombus did not necessarily indicate an advanced form of disease. Tumor size and AFP had greater impact on long-term outcomes than bile duct tumor thrombus. Major liver resection with a selective bile duct preserving approach in HCC with BDTT can achieve favorable outcomes comparable to those of HCC without BDTT in selected patients.     

原发性肝癌侵犯胆道的超声及病理学特征

目的　分析原发性肝癌侵犯胆道后的超声影像特征及其与病理类型的关系。方法　 34例经手术证实的原发性肝癌侵犯胆道病人在术前分别进行了一次或多次B型超声检查 ,其手术切除标本均进行了病理学检查 ,对B超检查时出现的“双筒枪征”、“乳头征”及病理学特征进行了分析。结果　术前发现肝脏占位的例数为 2 6例 (76 .5 % ) ,肝癌直径在 2 - 13cm之间 ,胆总管扩张、胆道内异常回声、肝内胆管扩张及合并门静脉癌栓的比例分别为 70 .6 %、5 8.8%、5 2 .9%和 4 4 .1% ,病理学检查发现浸润型及弥漫型肝癌易发生胆道转移。结论　B型超声检查是诊断肝癌侵犯胆道的较好方法 ,配合其他影像学检查手段 ,将进一步提高术前确诊率     

Curative resection of hepatocellular carcinoma with intrabile duct tumor growth mimicking hilar bile duct carcinoma

A 62-year-old Japanese male was admitted with obstructive jaundice and underwent percutaneous transhepatic cholangiodrainage (PTCD). An initial diagnosis was made of hilar bile duct carcinoma, based on demonstrated irregular stenosis of the hilar hepatic bile ducts without obvious tumor within the liver and negative alpha-fetoprotein (AFP). Enhanced computed tomography (CT) showed an irregular low density area around the hepatic hilum and the umbilical portion of the portal vein, suggesting carcinomatous invasion with blood flow disturbances. In contrast, intraoperative ultrasonography (US) raised the suspicion of an ill-defined lesion in Couinaud's segment 2 (segment 2) and intrabile duct tumor formation. A radical extended left and caudate lobectomy of the liver was successfully performed, with additional resection of extrahepatic bile duct and enbloc resection of regional lymph nodes. Unexpectedly, histological analysis of the resected specimen showed the final diagnosis to be hepatocellular carcinoma (HCC) of segment 2 with intrabile duct tumor growth. This case demonstrates that HCC with intrabile duct tumor growth toward the heptic hilum can mimic hilar bile duct carcinoma, when the tumor itself is equivocal on preoperative imaging and AFP is negative. In such cases, intraoperative US and guided biopsy may be of value for definitive diagnosis and selection of the optimal procedure.     

肝癌合并门静脉或胆管癌栓的综合治疗

The prognosis of hepatocellular carcinoma (HCC)is poor,and tumor thrombus in the portal vein or in the bile duct is an important influencing factor.Approximately 30%of HCC patients are found to have portal vein tumor thrombus (PVTT)when diagnosed,and their median survival time is about 2.7-4.0 months if they do not receive any treatment.The incidence of HCC complicated with bile duct tumor thrombus (BDTT)is less than 10%,while the prognosis is dismal.Once tumor thrombus extends to the major bile ducts,obstructive jaundice and subsequent hepatic dysfunction are inevitable.The survival time of patients with HCC complicated with BDTT is less than 4 months if they only receive palliative biliary stenting.The management of HCC complicated with PVTT or BDTT is challenging with controversy at present.Different treatment approaches and their benefits for patients with HCC complicated with PVTT or BDTT are introduced in this paper.     

肝细胞癌合并胆管癌栓的CT表现及临床应用价值

目的分析肝细胞癌（HCC）合并胆管癌栓的CT表现，以期提高对HCC合并胆管癌栓的影像诊断水平。 方法收集2012年1月至2018年9月中山大学附属第一医院和江门市新会中医院26例HCC合并胆管癌栓患者资料，病例均经手术后病理证实，并行64排螺旋CT平扫及双期（动脉期和门静脉期）增强扫描。回顾性分析其CT表现，包括受累胆管的位置、胆管内癌栓的密度、强化方式、肝内肿块与胆管癌栓的关系、胆管壁的情况。以手术及病理结果为"金标准"，分析CT对HCC合并胆管癌栓定位及定性的准确性。 结果26例均明确诊断为肝内肿块及胆管内肿块，HCC和胆管癌栓在CT上均清楚显示。原发HCC的CT增强扫描表现为三种强化方式："快进快退"18例（69.2%），"快进慢退"4例（15.4%），"三低"4例（15.4%）；胆管癌栓CT表现为扩张的胆管内填充有软组织块影，胆管远端扩张，胆管壁无增厚。24例（92.3%）HCC与癌栓相连，2例（7.7%）HCC与胆管癌栓不相连。增强扫描25例（96.2%）癌栓强化方式与肝内肿瘤的强化方式一致，1例（3.8%）强化方式不一致。CT对HCC合并胆管癌栓的检出例数、成像位置与手术及病理结果基本一致，准确性为100.0%（26/26）。 结论HCC合并胆管癌栓的CT表现具有一定的特征性，仔细分析肝内肿块及胆管内癌栓的CT表现，有助于疾病诊断。     

Mass-forming intrahepatic cholangiocarcinoma with portal vein tumor thrombus and bile duct tumor thrombus: A case report

IntroductionWe report the first case of mass-forming intrahepatic cholangiocarcinoma (ICC) with portal vein tumor thrombus (PVTT) and bile duct tumor thrombus (BDTT), where the extrahepatic bile duct was preserved with thrombectomy.Presentation of caseA 70-year-old male. Magnetic resonance imaging (MRI) showed the tumor extending from the hepatic hilum to the left hepatic duct with complete obstruction of the left hepatic duct and a defect at the left portal vein. We planned to perform extended left lobectomy, lymph node dissection, extra hepatic bile duct resection and reconstruction based on the diagnosis of mass-forming ICC with left portal vein and left hepatic duct infiltration (cT3N0M0 Stage III). Intraoperative cholangiography revealed a crab claw-like filling defect at the left hepatic duct, which suggested tumor thrombus. Accordingly, we performed thrombectomy. The margin of the left hepatic duct was tumor negative, so we performed extended left lobectomy, lymph node dissection and thrombectomy. Pathologically, the tumor was diagnosed as ICC (pT4N0M0 Stage IVA, vp3, b3). Tumors in the left hepatic duct and left portal vein proved to be tumor thrombus. The postoperative course was uneventful. He is doing well without recurrence.DiscussionThrombectomy is performed for hepatocellular carcinoma (HCC) with tumor thrombus. Furthermore, extrahepatic bile duct resection and reconstruction are recommended for ICC. In this case, intraoperative cholangiography was effective for precisely diagnosing. Thrombectomy could reduce surgical stress and prevent complications.ConclusionsThrombectomy can be a valid option for ICC with tumor thrombus, as well as for HCC.     

肝细胞肝癌合并胆总管癌栓的外科治疗

目的 通过对肝细胞肝癌合并胆总管癌栓手术病例临床资料的回顾性分析,探讨不同手术方式的疗效以及对远期预后的影响.方法 2008年1月-2012年12月,北京协和医院肝脏外科收治肝细胞肝癌合并胆总管癌栓行手术病例共9例,5例病例行根治性半肝切除术,3例行肝部分切除术,1例行术中射频,全部病例均行胆总管探查取栓术;术后通过数字减影血管成像技术进行随诊;全部病例术后随访时间均超过12个月.结果 全部手术病例术后黄疸指数均明显下降,根治性手术病例术后无瘤生存时间、生存时间均略优于姑息手术病例,术后再次胆道梗阻发病率也低于姑息手术病例.结论 肝细胞肝癌合并胆总管癌栓病例通过适当的手术方式可以达到切除肿瘤、解除胆道梗阻的目的,根治性半肝切除术的疗效优于肝部分切除术.