巨大肝癌手术切除治疗的远期疗效

背景与目的：巨大原发性肝癌(直径≥10cm)在临床上占有较大的比例,但关于其手术切除治疗的远期疗效报道较少。本研究探讨手术切除治疗巨大肝癌的远期疗效和预后影响因素。方法：回顾性分析我院1964年至1993年经手术切除的173例巨大肝癌患者的病例资料,根据随访结果计算生存率并作单因素及多因素分析。结果：术后3、5和10年累积生存率分别为31．9％、21．8％和8．3％;生存5年以上37例,生存10年以上8例;单因素分析结果表明预后影响因素为性别、术前肝功能Child-Pugh分级、术中肝硬化程度和是否根治性切除;多因素分析得出影响巨大肝癌切除术后远期疗效的独立预后因素为术中肝硬化程度和是否根治性切除。结论：巨大肝癌应积极争取手术切除治疗,术后能否长期生存取决于肝硬化程度和是否根治性切除。     

Laparoscopic liver resection for cancer

The field of laparoscopic liver resection surgery has rapidly evolved, with more than 1000 cases now reported. Laparoscopic hepatic resection was initially described for small, peripheral, benign lesions. Experienced teams are now performing laparoscopic anatomic resections for cancer. Operative times improved with experience. When compared with open cases, blood loss was less in most laparoscopic series, but was the main indication for conversion to an open procedure. Patients undergoing laparoscopic resection had shorter length of hospital stay and quicker recovery. Perioperative complications were comparable between the two approaches. Importantly, basic oncologic principles were maintained in the laparoscopic liver resections. The purpose of this review is to summarize the data available on outcomes for laparoscopic hepatic resection for cancer. This includes primary hepatocellular carcinoma, as well as metastatic colorectal cancer to the liver. The evidence to date suggests that laparoscopic results are comparable with the open approach in cancer patients.     

Anal Sphincter Function after Intersphincteric Resection for Low Rectal Cancer

Objective:To assess the anal sphincter function after intersphincteric resection for low rectal cancer by questionnaire and vectorial manometry.Methods:twenty five patients underwent intersphincteric resection,the controls contained 25 patients of rectal cancer who underwent low anterior resection and 25 healthy people.The therapeutic responses were evaluated using the Vaizey and Wexner scoring systems and vectorial manometry.Results:The Vaizey and Wexner scores after intersphincteric resection were significantly higher than those of low anterior resection controls at one month,but had no significant difference one year after.On the other hand,the indexes of vectorial manometry still had significant difference one year later.The indexes after intersphincteric resection could not reach the normal level.Conclusion:The anal sphincter function after intersphincteric resection is lower than that after low anterior resection in short term,although the long-term results can be accepted,it still can not reach the normal level.     

Hepatic resection after systemic chemotherapy for liver metastasis of colorectal cancer

We report 8 cases of hepatic resection after systemic chemotherapy for metastatic colorectal cancer. Three patients had unresectable hepatic lesions, and 5 patients were given neoadjuvant chemotherapy. The mean age was 69 (range: 55-81). Five patients received an oxaliplatin based regimen, 4 patients received irinotecan based regimen and 1 patient received UFT/LV. Four patients were treated with bevacizumab, and 2 patients with cetuximab. Duration of chemotherapy was 12 weeks (the mid range of 7-90 weeks). Six patients were PR, and 2 were SD. Although 1 patient had a minor biliary fistula, no major complications were observed. The duration of postoperative hospital stay was 17 (the average range of 13-22). Our results suggest that preoperative chemotherapy for hepatic resection of metastatic colorectal cancer is safe and has no adverse effect on surgery.     

The role of adjuvant therapy after liver resection for colorectal cancer metastases

Intrahepatic recurrence is common after major resection for colorectal cancer (CRC) metastases to the liver. In this review, the available data on different adjuvant therapies from systemic chemotherapy to regional approaches by direct perfusion of chemotherapeutic agents via the hepatic artery and portal vein will be discussed. Intraperitoneal administration of chemotherapy is another form of regional therapy. Novel approaches with immunotherapy and trials of neoadjuvant therapy in association with resection of CRC hepatic metastases have also been reported. The purpose of this review is to outline these various strategies and their role in combination with resection of CRC liver metastases. Although improved hepatic disease-free survival has been demonstrated with some strategies, overall survival is minimally affected and recurrence of metastatic disease at distant sites is still a major problem. Therefore, future directions should incorporate the use of new systemic agents effective against CRC metastases. Identification of subgroups through clinical features, molecular markers, proteins, or specific tumor properties may also help to individualize treatment.     

甲状旁腺自体移植术后移植甲状旁腺的功能评价

目的评价甲状旁腺自体移植术后移植甲状旁腺的分泌功能。方法2010年9月至2012年5月在北京大学肿瘤医院行甲状腺肿瘤手术术中甲状旁腺自体移植41例,术中将已无法保留的甲状旁腺切成碎块,以注射器移植入非正力手侧肱桡肌内,分别于手术结束当天、术后第3天、1周及1个月检测双侧肘部头静脉血清甲状旁腺素（parathyroid hormone,PTH）水平并对比分析。结果41例患者中,共检出甲状旁腺51枚,术后测量移植侧及非移植侧肘部头静脉血清PTH均值分别为：手术当天检测38例,移植侧34．02pg／mL,非移植侧25．02pg／mL;术后3天检测39例,移植侧27．57pg／mL,非移植侧24．99pg／mL;术后1周检测40例,移植侧37．23pg／mL,非移植侧26．59pg／mL;术后1个月检测34例,移植侧87．21pg／mL,非移植侧30．04pg／mL。双侧差异均有统计学意义（均P〈0．05）。结论甲状旁腺自体移植是保存甲状旁腺功能的可靠方法,移植的甲状旁腺可以成活,在术后1个月内即可恢复分泌功能。     

Adjuvant chemotherapy after resection of liver metastases from colorectal cancer

Colorectal liver metastases are common and found in almost 50% of patients with colorectal cancer. Surgical excision, whenever possible, is the optimum form of treatment and should be carried out with the intention of removing all macroscopic disease (R0 resection). However, recurrence frequently occurs within the remaining liver as well as at extra-hepatic sites. The role of adjuvant systemic chemotheraphy in an attempt to reduce the incidence of recurrence has been investigated in several studies. This review discusses the possible incorporation of adjuvant systemic chemotheraphy following liver resection.     

A case of liver failure associated with liver damage due to mFOLFOX 6 after resection for multiple liver metastases from colorectal cancer

A case of colorectal cancer in a 60-year-old man became resectable after downstaging was achieved with mFOLFOX 6 for multiple liver metastases from colorectal cancer. The patient received 8 cycles of mFOLFOX 6 on the basis of a diagnosis of multiple liver metastases in the right and left lobes and a single metastasis in the right lung. After chemotherapy, the liver metastases showed partial response, and the lung metastasis stable disease. Because the lung metastasis was controlled and radical cure of the liver metastases was thought possible by resection, we performed right lobectomy of the liver. Postoperative progress was good, and we then planned a staged partial resection of the lung. However,on postoperative day 28, the patient was hospitalized again with liver dysfunction, which evolved into liver failure, in spite of conservative treatment. The patient died on postoperative day 95. The needle biopsy specimens of the liver taken on readmission showed bile duct occlusion, portal hypertension, and perisinusoidal fibrosis, and histopathology of the surgical non-tumoral liver specimen showed the same findings. We think that liver failure was triggered by resection of the liver which had been damaged by mFOLFOX 6. Recently, liver damage due to oxaliplatin was reported, and evaluation of liver injury is considered important before liver resection for colorectal liver metastases with neoadjuvant FOLFOX.     

肝细胞癌术后复发的精准防治现状及对策

术后复发已成为影响肝细胞癌（hepatocellular carcinoma,HCC）预后的主要障碍。HCC术后复发转移的机制及其预测和干预是近年来的研究热点。影响HCC术后复发因素包括肿瘤临床病理特征、分子生物学特性、肝病背景及肿瘤微环境等。可依据肿瘤临床分期、相关分子标志物、多分子预测模型对HCC复发风险进行精确评估、识别及预测,用液体活检技术进行术后复发转移监测。对HCC高复发风险患者及早给予综合有效的精准防治有助于降低其复发风险,改善患者预后;术后抗病毒治疗和干扰素辅助治疗亦可降低HCC患者复发风险;辅助性TACE和索拉非尼靶向治疗的作用尚需进一步评估。近年来免疫治疗技术不断发展,必将为HCC转移复发预测和防治带来无限光明的前景。     

Surveillance after resection for colorectal cancer

BACKGROUND:

Professional societies recommend posttreatment surveillance for colorectal cancer (CRC) survivors. This study describes the use of surveillance over time, with a particular focus on racial/ethnic disparities, and also examines the role of area characteristics, such as capacity for CRC screening, on surveillance.

METHODS:

Surveillance, Epidemiology, and End Results (SEER)‐Medicare data were used to identify individuals aged 66 to 85 years who were diagnosed with CRC from 1993 to 2005 and treated with surgery. The study examined factors associated with subsequent receipt of a colonoscopy, carcinoembryonic antigen (CEA) testing, primary care (PC) visits, and a composite measure of overall surveillance.

RESULTS:

Of eligible subjects, 61.0% had a colonoscopy, 68.0% had CEA testing, 77.1% had PC visits, and 43.0% received overall surveillance. After adjustment, blacks were less likely than whites to undergo colonoscopy (odds ratio [OR] 0.76, 95% confidence interval [CI] = 0.69‐0.83) and to receive CEA testing and overall surveillance, whereas white/Hispanic rates did not differ. Rates for all outcomes increased from 1993 to 2005, but black/white disparities remained. Individuals in areas with greatest capacity for CRC screening were more likely (OR = 1.09, 95% CI = 1.02‐1.18) to receive colonoscopy, and those in areas with the greatest percentage of blacks were less likely (OR = 0.89, 95% CI = 0.83‐0.95) to receive colonoscopy. Those living in areas with shortage of PC were less likely to receive PC visits (OR = 0.55, 95% CI = 0.48‐0.64) and overall surveillance (OR = 0.83, 95% CI = 0.71‐0.98).

CONCLUSIONS:

Many CRC survivors do not get recommended surveillance, and black/white disparities in rates of surveillance have not improved. Characteristics of the area where an individual lives contribute to the use of surveillance. Cancer 2013. © 2012 American Cancer Society.     

Strategy of two-step resection for massive liver cancer

Unquestionably, the best way for treating primary liver cancer is the early detection and operation; unresectable PLCs still account for most of the clinical PLCs and lose their operable chance. Therefore, how to markedly shrink the massive liver cancer to smaller size for surgical remove is one of the hot points in the therapy of hepatic carcinoma.[1,2] From June 1987 to December 1997, 10 of the 73 patients (13.5%) with unrespectable PLCs, were treated with two-step resection. The results…     

直肠癌低位前切除术后肠功能改变的研究

直肠癌低位前切除术后,患者往往出现大便次数增多,大便失禁等排便功能障碍.研究表明,其功能障碍与新建直肠顺应性改变、肛门内括约肌功能损伤、内括约肌神经反射通路损伤、排便感觉变化等病理生理机制有关.     

直肠癌术后肝转移患者FOLFIRI化疗后肠道黏膜功能变化分析

目的:探讨直肠癌手术治疗后发生肝转移患者采用FOLFIRI方案（5-氟尿嘧啶+四氢叶酸钙+伊立替康）化疗对患者肠道黏膜功能的影响作用。方法:观察我院肿瘤科2011年9月至2013年8月收集的55例直肠癌术后发生肝转移患者采用FOLFIRI化疗方案前后肠道黏膜功能的变化情况,检测化疗前与化疗后不同时间患者血清白蛋白、前白蛋白、血浆D-乳酸、尿液中乳果糖/甘露醇（L/M）值、血浆内毒素值的水平。结果:55例患者血清白蛋白化疗前为（37.62±1.72）g/L、前白蛋白为（367.4±7.3）mg/L,均显著高于化疗后第1、3、7、9天(P<0.05),化疗后第9天的血清白蛋白、前白蛋白化疗后第7天有所升高（P<0.05）。化疗后第1、3、7、9天的血浆D-乳酸水平较化疗前明显升高（P<0.05）。与化疗前相比,化疗后第1、3、7、9天的L/M值表现为逐渐上升趋势,化疗后第9天的L/M值显著高于化疗前（P<0.05）。化疗前本组患者均无腹痛、腹泻发生,随着化疗时间的延长,化疗患者的腹痛、腹泻率逐渐增高,在化疗第7天达到最高值（腹痛率87.27%、腹泻率34.55%）,在化疗后第9天有所降低（腹痛率83.64%、腹泻率27.27%）。结论:直肠癌术后肝转移患者采用FOLFIRI方案治疗会引起肠道黏膜功能障碍,肠道通透性增加。     

Histopathological prediction of liver metastasis after curative resection of colorectal cancer.

To estimate the risk of liver metastasis after curative resection of colorectal cancer, resected specimens from 290 patients (45 with metachronous liver metastasis) were examined and the relationships between 10 histopathological variables and liver metastasis were analysed using our application of the Akaike information criterion (AIC). Of the 10 variables examined, the depth of venous invasion (Vd) had the greatest prognostic value for metastasis, followed by the number of venous invasions, the number of lymphovascular invasions, lymph node metastasis and type of infiltration. The prediction of liver metastasis was further improved by combining Vd with lymphocyte infiltration, mucinous production, interstitial fibrosis or depth of penetration, although these four variables per se were minimally informative for metastasis. We conclude that the prediction of liver metastasis is best achieved by combining Vd with other variables. Our risk group classification, and the estimated probability of liver metastasis for each group, are shown.     

Curative liver resection for metastatic breast cancer.

AIMS: Hepatic resection is a standard procedure in the treatment of colorectal liver metastases. Liver metastases are frequent in breast cancer, but resectional treatment is rarely possible and few reports have addressed the results of surgical treatment for metastatic breast cancer. The aim of our study was to analyse the outcome of patients with metastatic breast cancer after resection of isolated hepatic secondaries and possibly to identify selection criteria for patients who may benefit from surgery. METHODS: Between 1984 and 1998, 90 patients with a history of breast cancer and suspected liver metastases were referred for surgical evaluation. Fifty-four patients also had extrahepatic disease or metastases from another primary tumour; multiple liver metastases were not amenable to surgical treatment in 20 patients. Five patients were treated by regional chemotherapy via an intra-arterial port catheter; after liver resection two patients were found to have liver metastases from intercurrent colorectal cancer. Thus only nine liver resections for metastatic breast cancer could be performed with curative intent. RESULTS: No patient died post-operatively after liver resection. In the follow-up period, four of the nine patients who were treated with curative intent received systemic chemotherapy. At a median follow-up of 29 months, four patients died from tumour recurrence. Five patients are currently alive. Five-year survival in the resection group was calculated as 51% (Kaplan-Meier estimate). Node-negative primary breast cancer and a long interval between treatment of the primary and liver metastases appeared to be associated with long survival after liver resection. CONCLUSIONS: These observations suggest that careful follow-up and adequate patient selection could offer some patients with isolated liver metastases from breast cancer a chance of long-term survival.     

Indication for hepatic resection after hepatic arterial infusion chemotherapy for multiple liver metastases of colorectal cancer

The indications for hepatic resection after hepatic arterial infusion chemotherapy (HAI) for unresectable metastatic liver tumor of colorectal cancer were analyzed from the surgical outcome of hepatic resections in 23 cases of hepatic resection after HAI. The mean duration of HAI until hepatic resection was 7.4 months (5-14 months). The total dose of 5-FU was 25.7 +/- 8.0 g for a CR + PR group and 14.0 +/- 3.5 g for a NC + PD group. There was a significant difference between two groups (p < 0.01). The group in which serum CEA level normalized after HAI (the normal CEA group) included 7 patients, and the group in which serum CEA level did not normalize (the high CEA level group) had 9 patients. The total dose of 5-FU was 30.0 +/- 7.6 g in the normal CEA level group and 19.1 +/- 6.9 g in the high CEA level group. There was a significant difference between the two groups. The 3-year survival rate was 40.0% in the group with the duration of HAI for longer than 8 months (n = 10) and 0% in the group with the duration of HAI for shorter than 8 months (n = 7). The 3-year survival rate was 66.7% in the normal CEA level group (n = 3) and 0% in the high CEA level group (n = 8). The surgical outcome was better in the HAI for longer than 8 month and normal CEA groups.     

Intrathoracic anastomosis after oesophageal resection for cancer

Cervical anastomosis has been advocated to avoid the pulmonary complications and life-threatening anastomotic disruptions following intrathoracic oesophagogastric anastomosis. This is a retrospective review of 111 oesophageal resections followed by an intrathoracic anastomosis. These resections were performed between September 1993 and August 1994 within a residency training program. The left thoracoabdominal approach was used for distal tumours and the Ivor Lewis technique for more proximal tumours. Squamous cell carcinoma accounted for 72% patients (n = 80), adenocarcinoma for 25% (n = 28), and others for 2.7% patients (n = 3). Of the patients, 69% had pathologic Stage III tumours. Operative mortality rate was 1.8% (two patients). Perioperative complications occurred in 39 patients, including anastomotic leak in 10 patients and myocardial infarction in 2 patients. In the absence of a leak, there were no major pulmonary complications requiring intensive care or ventilatory support. Of those patients with anastomotic disruption, 89% were salvaged by early clinical diagnosis and appropriate treatment. We conclude that transthoracic oesophagectomy with an intrathoracic anastomosis is a safe procedure that can be performed with low mortality and acceptable morbidity. © 1996 Wiley-Liss, Inc.     

Long-term survival case after liver resection and postoperative hepatic arterial infusion for multiple liver metastases from rectal cancer

A 45-year-old man underwent a low anterior resection for rectal cancer [T3, N1, M0, Stage IIa: UICC]. He received a postoperative systemic chemotherapy with 5-FU and LV. Five months after the operation, multiple liver metastases were detected in the right hepatic lobe (S5, 6, 8). Right hepatectomy was performed. Seventeen courses of postoperative hepatic arterial infusion (HAI) chemotherapy (weekly high-dose 5-FU regimen) were performed without severe adverse events. He was still alive with no sign of recurrence for 69 months after hepatectomy. After liver resection for metastases of colorectal cancer, although a systemic chemotherapy has been mainly performed, HAI chemotherapy is one of the important options for prevention of local recurrence.     

原发性肝癌的三级根治切除标准

目的阐述原发性肝癌三级根治切除标准的内容并评价其临床意义.方法根据根治标准的完善程度将肝癌根治切除标准分为3级.Ⅰ级标准完整切除肉眼所见肿瘤,切缘无残癌.Ⅱ级标准在Ⅰ级标准基础上增加4项条件(1)肿瘤数目不超过2个;(2)无门脉主干及一级分支、总肝管及一级分支、肝静脉主干及下腔静脉癌栓;(3)无肝门淋巴结转移;(4)无肝外转移.Ⅲ级标准在Ⅱ级标准基础上增加术后随访结果阴性条件,即术后2个月内AFP降至正常(术前AFP阳性者)和影像学检查未见肿瘤残存.回顾性分析354例肝癌患者行肝切除治疗的临床资料,按3级标准的根治与否分为6组Ⅰ级标准根治组,Ⅰ级标准姑息组;Ⅱ级标准根治组,Ⅱ级标准姑息组;Ⅲ级标准根治组,Ⅲ级标准姑息组.寿命表法计算各组生存率,并加以比较.结果原发性肝癌各根治切除组生存率均高于相应姑息组(P<0.01).随着采用根治标准级别的升高,其切除后生存率也逐级提高,Ⅰ级、Ⅱ级和Ⅲ级标准根治组5年生存率分别为43.2%、51.2%和64.4%,各组生存率差异有显著性(P<0.01).结论原发性肝癌手术切除可以采用分级根治标准判定手术根治性.所应用的根治标准越严格,其获得的疗效越好.按较高级别肝癌根治切除标准选择病例、实施手术和加强随访,将提高肝癌切除手术疗效.