肝癌的冷冻治疗

冷冻疗法已成为治疗不能手术切除肝癌的重要手段.冷冻方法可选择手术中冷冻,切除或不切除肿瘤、腹腔镜下冷冻,或在超声、cT或MRI监测下,经皮冷冻.作为一局部治疗,冷冻具有超越其他治疗方法的若干优点:仅消融肝内肿瘤组织,而少伤及正常组织;由于大血管流动血流的温热作用,冷冻可安全地治疗临近大血管的肝肿瘤:冷冻比之手术更适宜治疗肝多发性肿瘤.冷冻联合肝动脉化学栓塞(TACE)、酒精注射或125碘粒子植入,有相辅相成的作用.对于冷冻在肝癌治疗中应用,可归结如下:(1)小于5 cm,尤其小于3 cm的肝癌,数目不超过3个,可以手术中冷冻或经皮冷冻.(2)大于5 cm的肝癌,先作TACE,再给予经皮冷冻.(3)大于5 cm,边缘不整,预计冷冻不完全的肝癌,可予手术中或经皮冷冻,同时在冷冻区周边部注射酒精或植入125碘粒子.     

经皮埋置125碘籽治疗不能切除性胰腺癌

目的 研究经皮埋置^125碘籽对不能手术切除性胰腺癌的治疗价值。方法 在B超监视下，经皮穿刺注入^125碘籽入胰肿瘤内。按肿瘤大小，注入30～80粒，放射活性15～40mCi。结果 13例均为不能手术切除的进展期胰腺癌，经^125碘籽局部埋置后，69．2％的病例腹痛改善，38．5％的病例腹痛几乎完全消失；53．8％的病例肿瘤缩小；中位生存期13个月，6、12、18和24个月生存率分别为92.3％、53．8％、38．5％和15．3％。结论 经皮植入^125碘籽对病人的侵袭性小，而取得的结果与常规手术、放化疗的结果大体相似，可作为不能切除性胰腺癌的治疗手段。     

PCTI联合TACE治疗中晚期肝癌16例疗效观察

目的观察经皮肝瘤内注射术（PCTI）联合经导管肝动脉化疗栓塞术（TACE）治疗无法手术切除的中晚期肝癌的效果。方法无法手术切除的中晚期肝癌16例,采用PCTI联合TACE治疗。结果本组生存期最长98个月,最短15个月,中位生存期为56个月;肿瘤直径缩小3~5 cm 13例,缩小1~3 cm 3例;肝区疼痛缓解6~10个月14例,1~5个月2例;治疗后1~6个月饮食及体质量均增加。结论 PCTI联合TACE治疗无法手术切除的中晚期肝癌安全有效,可明显延长患者生存期。     

冷冻加放射性碘粒子植入治疗局部进展型胰腺癌

目的 探讨术中或经皮冷冻加125I粒子植入对局部进展型胰腺癌的治疗价值.方法 对38例经过综合评价被认为不能接受手术切除的局部进展型胰腺癌采用手术中或经皮冷冻加125I粒子植入方法进行治疗.125I粒子植入系在手术直视下或在超声或CT引导下经皮穿刺完成.8例患者人院前接受过4～6个周期化疗.治疗后3个月做CT评价肿瘤治疗反应.结果 11例患者接受术中冷冻,27例接受经皮冷冻,其中14例接受2次冷冻,3例接受3次冷冻.29例在冷冻的同时行肿瘤内125I粒子植入,9例在术后于超声或cT引导下行125I粒子植入.15例(其中13例伴胰周淋巴结或肝转移)患者行区域动脉化疗.CR、PR、SD和PD分别为9例、16例、10例和3例.20例(52.6%)患者出现上腹痛,16例(42.1%)血清淀粉酶升高,5例(13.2%)并发AP,其中1例为SAP,均经保守治疗痊愈.无治疗相关性死亡.随访5～37月,中位生存期12个月,6、12、24和36个月总生存率分别为94.7%、49.4%、21.8%和5.4%.接受化疗患者的6、12、24和36个月生存率分别为93.3%、26.6%、0和0,未接受化疗者生存率分别为95.6%、65,9%、19.8%和9.9%,两组相差显著(P＜0.01).生存期最长的2例分别为31和37个月,目前无任何复发证据.病死29例,12个月内共病死15例.结论 对大多数胰腺癌尤其不能手术切除患者,冷冻治疗有良好疗效,不良反应发生率较低.在冷冻同时或其后加用125I粒子植入,与冷冻治疗有相辅相成之效.     

腹腔镜联合射频消融和125I粒子治疗肝转移癌

目的探讨腹腔镜切除并联合应用射频消融和^125I粒子植入治疗肝转移癌的临床价值。方法对62例术前经CT或MR确诊肝脏有转移灶的患者，行腹腔镜下肝转移瘤切除或射频消融，最后将^125粒子植入肝脏肿瘤部位。结果术中超声发现新病灶17个，所有患者均顺利行腹腔镜切除或射频消融及^125粒子植入。2例术后出现肝脓肿，1例术后发生腹腔少量出血，余无严重并发症。^125个转移病灶位于肝脏右后内叶或巨大仅行腹腔镜下射频消融及^125粒子植入，22例患者的38个边缘转移病灶行离体切除。随访12～25个月（平均22．3个月），有12例转移癌未见液化，行腹腔镜下二次射频及^125粒子植入。1年生存率为74．2％（46／62），2年生存率为59．7％（37／62）。结论腹腔镜切除并联合应用射频消融和^125粒子植入治疗肝转移癌具有微创、安全、有效，术后恢复快等优点。     

经皮微波固化联合无水酒精注射治疗原发性肝癌25例疗效观察

经皮肝穿刺无水酒精注射(PEI)治疗肿瘤直径<3cm的小肝癌,疗效与外科手术相仿;但对于大肝癌,由于无水酒精不能渗透整个瘤体,故影响疗效。2000年8月～2004年12月,我们采用经皮微波固化(PMTC)联合PEI治疗原发性肝癌,取得满意疗效。现报告如下。1资料与方法1.1一般资料本组25例均为我院住院患者,全部经活检病理证实为原发性肝细胞癌,男20例,女5例;年龄45～69岁,中位年龄56岁。其中AFP阳性(≥400ug/L)13例;肿瘤直径3.5～12cm者22例,<5cm者3例;肿瘤数目≤3个。本组均为初治患者,拒绝手术或肿瘤无法切除,未有远处转移,肝功能正常。1.2治疗方…     

肝癌冷冻治疗的临床研究进展

对于不能手术切除的肝癌,无论是原发或是继发,冷冻治疗都是一种重要选择。冷冻治疗具有坏死彻底、适应性广、创伤小、可控性强等优点;冷冻消融后的瘤苗作用还能提高患者的抗肿瘤免疫力,冷冻导致的血管栓塞能阻止肿瘤通过血行转移;冷冻治疗不仅能用于治疗小肝癌,对大肝癌和邻近大血管的肝癌均适用。冷冻疗法可在手术中应用,也町经腹腔镜或经皮穿刺完成治疗过程;在超声或CT引导下,经皮氩氦刀冷冻消融对于小肝癌的治疗效果等同于外科手术.     

经皮肝脏化疗药物灌注诱导晚期肝癌长期缓解

对于存在着肝硬化或肝内转移的肝癌患者,手术切除的可能性不到30％,只能用动脉栓塞,经皮肿瘤酒精注射及动脉内插管化疗来得到症状上的缓解,然而这些治疗效果均不理想。此研究观察用肝静脉隔离及活性炭血灌流(HVI-CHP)作经皮隔离肝化学灌注对晚期肝癌的远期疗效。 方法:28例HCC患者中男25例,女3例,     

超声内镜引导125I粒子组织间植入治疗晚期胰腺癌的疗效及粒子移位分析

目的分析胰腺癌超声内镜（EUS）引导下^125I粒子种植术治疗晚期胰腺癌的肿瘤变化及粒子移位，并评价其治疗效果。方法对17例不能手术切除的中晚期胰腺癌患者行EUS引导下放射性^125I粒子内照射治疗。所有患者治疗前均参照治疗设计系统估算期望植入粒子数量。治疗后每月复查，观察治疗前、后肿瘤变化及粒子移位、脱落等情况。结果17例患者均经EUS植入^125I粒子成功。治疗前肿瘤最大长径平均值为5．4cm（3．7～9．0cm），平均植入粒子数量为27颗，平均每次植入粒子中位数为14（7～24）颗，平均植入2次。平均单颗粒子的放射性活度为（0.689±0．016）mCi。治疗后平均随访4．8个月（2～14个月）。治疗后3个月评估疗效，部分缓解5例（29．4％），疾病稳定7例（41．2％），进展恶化5例（29．4％）。治疗后腹部平片示5例（29．4％）出现粒子丢失移位。1例脾区移位，1例肝脏移位，3例肠腔移位。治疗后粒子丢失4例。1例出现脾脏及左膈下囊肿。结论EUS引导下^125I粒子内照射治疗晚期胰腺癌，可使粒子照射区域内病灶明显萎缩。但需注意放射性粒子对周围脏器的损害及粒子脱落移位等并发症的发生。     

125I粒子植入抑制荷肝癌裸鼠肿瘤生长的实验研究

建立荷肝癌裸鼠动物模型.治疗组在肿瘤组织内植入125碘(125I)粒子,对照组不进行任何干预.治疗21d后测量各组肿瘤体积并计算抑瘤率,切除肿瘤组织进行常规病理检查.结果治疗组和对照组平均肿瘤体积分别为(601.5±154.1)mm3和(1182.9±296.6)mm3,差异有显著性(P＜0.01);治疗组抑瘤率为49.2%.治疗组病理切片显示靠近125I粒子处肿瘤细胞坏死,但远离粒子处仍可见大量存活肿瘤细胞.对照组肿瘤细胞生长良好.表明125I粒子肿瘤组织内植入可抑制荷肝癌裸鼠肿瘤生长,杀死局部肿瘤细胞,但该粒子杀伤距离有限.     

A pilot study on combination of cryosurgery and (125)iodine seed implantation for treatment of locally advanced pancreatic cancer

AIM： To study the therapeutic value of combination o cryosurgery and 125iodine seed implantation for locally advanced pancreatic cancer. METHODS： Forty-nine patients with locally advanced pancreatic cancer （males 36, females 13）, with a median age of 59 years, were enrolled in the study. Twelve patients had liver metastases. In all cases the tumors were considered unresectable after a comprehensive evaluation. Patients were treated with cryosurgery, which was performed intraoperatively or percutaneously unde guidance of ultrasound and/or computed tomography （CT）, and 125iodine seed implantation, which was performed during cryosurgery or post-cryosurgery under guidance of ultrasound and/or CT. A few patients received regional celiac artery chemotherapy. RESULTS： Thirteen patients received intraoperative cryosurgery and 36 received percutaneous cryosurgery Some patients underwent repeat cryosurgery. 125Iodine seed implantation was performed during freezing procedure in 35 patients and 3-9 d after cryosurgery in 14 cases. Twenty patients, 10 of whom had hepaticmetastases received regional chemotherapy. At 3 mo after therapy, CT was repeated to estimate tumor response to therapy. Most patients showed varying degrees of tumor necrosis. Complete response （CR） of tumor was seen in 20.4% patients, partial response （PR）, in 38.8%, stable disease （SD）, in 30.6%, and progressive disease （PD）, in 10.2%. Adverse effects associated with cryosurgery included upper abdomen pain and increased serum amylase. Acute pancreatitis was seen in 6 patients one of whom developed severe pancreatitis. All adverse effects were controlled by medical management with no poor outcome. There was no therapy-related mortality. During a median follow-up of 18 mo （range of 5-40）, the median survival was 16.2 mo, with 26 patients （53.1%） surviving for 12 mo or more. Overall, the 6-, 12-, 24- and 36-mo survival rates were 94.9%, 63.1%, 22.8% and 9.5%, respectively. Eight patients had survival of 24 mo or more. The     

Cryosurgery with combination of (125)iodine seed implantation for the treatment of locally advanced pancreatic cancer

OBJECTIVE: To study the therapeutic value of cryosurgery with combination of (125)iodine seed implantation for locally advanced pancreatic cancer. METHODS: Thirty-eight patients with locally advanced pancreatic cancer were enrolled in this study. The diagnosis was confirmed by pathology in 31 patients. Ten patients had metastases of the peripancreatic lymph node and eight had liver metastases. The therapy included cryosurgery, which was performed intra-operatively or percutaneously under guidance of ultrasound and/or computed tomography (CT), and (125)iodine seed implantation, which was performed during cryosurgery process or post-cryosurgery under the guidance of ultrasound and/or CT. RESULTS: Eleven patients received intra-operative cryosurgery and 27 received percutaneous cryosurgery. Fourteen patients underwent two procedures of cryosurgery and three underwent three procedures of cryosurgery. (125)Iodine seed implantation was performed during the freezing procedure in 29 patients and within 3-7 days after cryosurgery in nine patients under ultrasound and CT guidance. Fifteen patients, of whom 13 had metastases of peripancreatic lymph nodes or liver received regional chemotherapy. At 3 months after therapy, a CT follow-up was performed to estimate the tumor response to therapy. Most of the patients had varying degrees of tumor necrosis. A complete response of the tumor was seen in 23.6% of patients, a partial response in 42.1%, stable disease in 26.3% and progressive disease in 7.9%. The adverse effects associated with cryosurgery mainly included pain of the upper abdomen and increased serum amylase activity. Acute pancreatitis was seen in five patients, one of whom presented a severe type of pancreatitis. During the followed-up of a median of 16 months (range of 5-37) median overall survival was 12 months, 19 patients (50.0%) survived for 12 months or longer and four survived for 24 months or longer. CONCLUSION: As it is far less invasive than conventional pancreas resection and entails a low rate of adverse effects, cryosurgery should be the choice modality for most patients with locally advanced pancreatic cancer. (125)Iodine seed implantation can destroy residue survival cancer cells after cryosurgery. Hence, combination of both modalities has a complementary effect.     

Percutaneous Cryoablation for Liver Cancer

Based on the primary tumor site, liver cancer can be divided into two categories: (1) primary liver cancer and (2) metastatic cancer to the liver from a distant primary site. Guided cryoablation via many imaging methods induces iceball formation and tumor necrosisand is an attractive option for treating unresectable hepatocellular carcinoma (HCC) and metastatic liver cancer. There are several advantages to using cryoablation for the treatment of liver cancer: it can be performed percutaneously, intraoperatively, and laparoscopically; iceball formation can be monitored; it has little impact on nearby large blood vessels; and it induces a cryo-immunological response in situ. Clinically, primary research has shown that percutaneous cryoablation of liver cancer is relatively safe and efficient, and it can be combined with other methods, such as radiation therapy, chemotherapy, and immunology, to control disease. Although research is preliminary, cryosurgery is fast becoming an alternative treatment method for HCC or liver tumors. Here, we review the mechanisms of liver tumor cryoablation, cryoablation program selection, clinical efficiency, and complications following treatment.     

Combination of cryosurgery and Iodine-125 seeds brachytherapy for lung cancer

It has been proven that radioactive seeds such as Iodine-125 seeds implantation is a highly effective treatment for patients with localized cancer, such as lung cancer. It may increase the effectiveness of cryosurgery for lung cancer with the combination of Iodine-125 seed implantation into edge of the cryoablation zone. Percutaneous cryosurgery and Iodine-125 seed implantation are mutual complementation; both have been proved to be safe and effective modality for unresectable lung cancer, especially for centrally located lung cancer. Well-designed, randomized and control study both in the laboratory and in the clinical about this option are needed before the conclusive evidence submits.KEY WORDS : Lung cancer, cryosurgery, cryoablation, Iodine-125 seeds     

从胰腺癌治疗探讨进展期癌症治疗策略

进展性或转移性胰腺癌患者预后恶劣。化疗是目前主要治疗方法。但无论是吉西他滨单用还是与其他药物联合应用,均不能有效延长患者生存期。以冷冻消融为主的综合治疗,可以延长进展性或转移性胰腺癌患者生存期。这一结果提示,采用将经皮冷冻（C）（125碘粒子植入）、肿瘤血管（微血管）介入（C）和联合免疫治疗（C）组合起来,个体化应用（P）,形成＂3C＋P模式＂,可作为治疗进展性肿瘤的新策略。     

Sequential use of transarterial chemoembolization and percutaneous cryosurgery for hepatocellular carcinoma

AIM： To evaluate the efficacy of sequential use of transarterial chemoembolization （TACE） and percutaneous cryosurgery for unresectable hepatocellular carcinoma （HCC）. METHODS： Four hundred and twenty patients were enrolled in this study. The patients, who were considered to have unresectable tumors due to their location or size or comorbidity, were divided into sequential TACE-cryosurgery （sequential） group （n = 290） and cryosurgery alone （cryoalone） group （n = 130）. Patients in the sequential group tended to have larger tumors and a greater number of tumors than those in the cryo-alone group. Tumors larger than 10 cm in diameter were only seen in the sequential group. TACE was performed with the routine technique and percutaneous cryosurgery was conducted under the guidance of ultrasound 2-4 wk after TACE. RESULTS： During a mean follow-up period of 42 ± 17 mo （range, 24-70 mo）, the local recurrence rate at the ablated area was 17% for all patients, 11% and 23% for patients in sequential group and cryoalone groups, respectively （P = 0.001）. The overall 1-, 2-, 3-, 4- and 5-year survival rate was 72%, 57%, 47%, 39% and 31%, respectively. The 1- and 2-year survival rates （71% and 61%） in sequential group were similar to those （73% and 54%） in cryo-alone group （P = 0.69 and 0.147）, while the 4- and 5-year survival rates were 49% and 39% in sequential group, higher than those （29% and 23%） in cryo-alone group （P = 0.001）. Eighteen patients with large HCC （〉 5 cm in diameter） survived for more than 5 years after sequential TACE while no patient with large HCC （〉 5 cm in diameter） survived more than 5 years after cryosurgery. The overall complication rate was 24%, and the complication rates were 21% and 26% for the sequential and cryo-alone groups, respectively （P = 0.06）. The incidence of hepatic bleeding was higher in cryo-alone group than in sequential group （P = 0.02）. Liver crack only occurred in two patients of the cryoalone group. CONCLUSION： Pre-cryosurgical TACE can increase the cryoablation efficacy and decrease its adverse effects, especially bleeding. Sequential TACE and cryosurgery may be the better procedure for unresectable HCC, especially for large HCC.     

Outcomes of ultrasound-guided percutaneous argon-helium cryoablation of hepatocellular carcinoma

Purpose

To evaluate the efficacy and safety of ultrasound (US)-guided percutaneous argon-helium cryoablation for hepatocellular carcinoma (HCC) and determine appropriate indications.

Methods

We reviewed outcomes of 300 HCC patients who underwent US-guided percutaneous cryoablation.

Results

Overall, 223 tumors (mean diameter 7.2?±?2.8?cm) in 165 patients were incompletely ablated, while 185 tumors (mean diameter 5.6?±?0.8?cm, P?=?0.0001 vs. incomplete ablation) in 135 patients were completely ablated. Nineteen patients (6.3%) developed serious complications while in hospital, including cryoshock syndrome in six patients, hepatic bleeding in five, stress-induced gastric bleeding in four, liver abscess in one and intestinal fistulas in one. Two patients died because of liver failure. The median follow-up was 36.7?months (range 6–63?months). The local tumor recurrence rate was 31%, and was related to tumor size (P?=?0.029) and tumor location (P?=?0.037). The mean survival duration of patients with early, intermediate and advanced HCC (Barcelona Clinic Liver Cancer staging system) was 45.7?±?3.8, 28.4?±?1.2 and 17.7?±?0.6?months, respectively.

Conclusions

US-guided percutaneous cryoablation is a relatively safe and effective therapy for selected HCC patients.     

Percutaneous cryoablation in combination with ethanol injection for unresectable hepatocellular carcinoma

AIM: To evaluate the effectiveness and safety of percutaneous hepatic cryoablation in combination with percutaneous ethanol injection (PEI) in patients with unresectable hepaocellular carcinoma (HCC).METHODS: A total of 105 masses in 65 HCC patients underwent percutaneous hepatic cryoablation. The cryoablation was performed with the Cryocare system (Endocare, Irvine, CA, USA) using argon gas as a cryogen.Two freeze-thaw cycles were performed, each reaching a temperature of -180 ℃ at the tip of the probe. PEI was given in 36 patients with tumor masses larger than 6 cm in diameter 1-2 weeks after cryoablation and then once per week for 4 to 6 sessions. The efficacy was evaluated with survival, change of tumor size and alpha-fetoprotein (AFP) levels.RESULTS: During a follow-up duration of 14 months in average with a range of 5 to 21 months, 33 patients (50.8%)were free of tumors, 22 patients (33.8%) alive with tumor recurrence: two had bone metastases, three were found to have lung metastases, and the remaining 17 recurrences occurred in the liver, of whom only 3 developed a cryosite recurrence. Among the 41 patients who were followed up for more than one year, 32(78%) were alive despite of tumor recurrence. Seven patients (10.8%) died due to disease recurrence. Three patients (4.6%) died due to some noncancer-related causes. Among the 43 patients who had a CT scan available for review, 38 (88.4%) had a shrinkage of tumor mass. Among the 22 patients who received biopsies of cryoablated tumor mass, all biopsies except one, showed only dead or scar tissues. Of the patients who had an increased AFP preablatively, 91.3% had a decrease of AFP to normal or nearly normal levels during postablative 3-6 months. Complications of cryoablation included liver capsular cracking in one patient,transient thrombocytopenia in 4 patients and asymptomatic right-sided pleural effusions in 2 patients. Two patients developed liver abscess at the previous cryoablation site at 2 and 4 months, respectively,following cryoablation, and was recovered after treated with antibiotics and drainage.CONCLUSION: Percutaneous cryoablation offers a safe and possibly curative treatment option for patients with HCC that cannot be surgically removed, and its integration with PEI, may serve as an alternative to partial liver resection in selective patients.     

经皮冷冻治疗结直肠癌肝转移

背景：结直肠癌肝转移的手术切除率低,其他疗法效果亦欠佳。目的：探讨经皮冷冻治疗结直肠癌肝转移的疗效和安全性。方法：于超声或CT引导下,对326例不能手术切除的结直肠癌肝转移患者行经皮冷冻治疗,术后定期随访。结果：326例患者共接受526次经皮冷冻治疗。治疗后3个月,基线CEA水平升高者中77．6％降至正常范围。280例接受CT随访者中,冷冻病灶完全反应（CR）者14．6％,部分反应（PR）41．1％,稳定（SD）24.3％,进展（PD）20．0％。中位随访期为36食月（7—62个月）,复发率为41．7％。全部病例中位存活期为29个月（3～62个月）。治疗后第1、2、3、4、5年存活率分别为78％、62％、41％、34％和23％：肿瘤直径≤3cm、肝右叶肿瘤、冷冻前CEA≤10μg／L、冷冻后原先升高的CEA降至正常、冷冻治疗2～3次和冷冻后行经导管肝动脉化学栓塞（TACE）治疗者存活率较高。严重并发症发生率为5．2％。结论：经皮冷冻治疗结直肠癌肝转移安全、有效,可作为肿瘤不能手术切除者的替代治疗手段。     

Radiofrequency ablation or percutaneous ethanol injection for the treatment of liver tumors

The liver is a common location of both primary and secondary malignancies. For unresectable liver cancer, many local ablative therapies have been developed. These include e.g., percutaneous ethanol injection (PEI), percutaneous acetic acid injection, radiofrequency ablation (RFA), cryoablation, microwave ablation, laserinduced thermotherapy, and high-intensity focused ultrasound. RFA has recently gained interest and is the most widely applied thermoablative technique. RFA allows more effective tumor control in fewer treatment sessions compared with PEI, but with a higher rate of complications. However, there are certain circumstances where PEI therapy represents a better strategy to control liver tumors than RFA, especially in situations where RFA is difficult, for example when large vessels surround the tumor. In the context of hepatocellular carcinoma (HCC), both RFA and PEI are feasible and of benefit in non-operable patients. RFA seems superior to PEI in HCC 2 cm, and the combination of interventions may be of benefit in selected patients. Liver resection is superior to RFA for patients with HCC meeting the Milan criteria, but RFA can be employed in tumors ≤ 3 cm and where there is an increased expected operative mortality. In addition, some lines of evidence indicate that RFA and PEI can be employed as a bridge to liver transplantation. The use of RFA in colorectal liver metastases is currently limited to unresectable disease and for patients unfit for surgery. The aim of this article is to summarize the current status of RFA in the management of liver tumors and compare it to the cheap and readily available technique of PEI.