肝癌的冷冻外科治疗72例

1材料和方法 1.1材料我院自1994年起,应用LSC-2000型冷冻机治疗肝癌72例,其中男63例,女9例,年龄30岁～65岁,平均47.7岁.其中原发性肝癌66例,转移性肝癌7例,均经病理证实.肿瘤最大直径＜5 cm者17例,5 cm～10 cm者34例,＞10 cm者21例.术前AFP＞400ng/L者35例(48.6%).仪器设备:①LCS-2000型冷冻机;②Toshiba SSA-240A型线阵实时超声显象仪,以及引导穿刺的全套设备;③Olympus腹腔镜及全套辅助设备;④WolfFoley扩张器,内径2mm～9mm.     

肝癌的局部治疗

在肝癌治疗中,除免疫治疗、静脉化疗、中药治疗等以全身非特异性用药为特征的治疗外,其它各种针对肿瘤局部开展的治疗,都属局部治疗范畴,它包括：局部手术切除、局部化疗栓塞、局部肿瘤间质内各种药物注入及局部高温、局部冷冻等疗法。本文拟对除肝癌局部手术切除外的...     

氩氦刀冷冻消融术治疗180例肝癌临床分析

目的探讨氩氦刀冷冻消融术治疗肝癌方法的安全性和近期疗效。方法选择180例肝癌患者在超声引导下行经皮穿刺氩氦刀冷冻治疗。术后定期复查肿瘤标志物及CT或MRI随访。结果小肝癌（≤5cm）患者135例,85%达到完全消融。大肝癌（〉5cm）患者45例,治疗后AFP降至正常范围或CT、MRI提示肿瘤完全坏死21例,占46.8%。转移性肝癌44例,治疗后肿瘤标志物降至正常或CT、MRI提示完全坏死30例,占68.2%。结论超声引导下肝癌的经皮穿刺氩氦刀冷冻消融术是一种安全、有效的治疗方法。     

肝癌的冷冻治疗

冷冻疗法己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；冷冻比手术更适宜治疗肝多发性肿瘤。冷冻联合肝动脉化疗栓塞（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〈5cm，尤其〈3cm的肝癌，数目不超过3个，可以手术中冷冻或经皮冷冻。②〉5cm的肝癌，先作TACE，再给予经皮冷冻。③〉5cm，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。     

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.     

肝癌的冷冻治疗

肿瘤的冷冻治疗指在原位通过低温和复温达到对肿瘤组织的灭活。对于无法手术切除的肝癌,冷冻治疗是目前较为理想的方法。温度低于－５０℃时,可对肿瘤达到理想的灭活,复温引起低张环境使细胞破裂。Korpan认为,对无法切除的肝癌冷冻治疗具有下列作用：①冷冻造成感觉神经灭活所产生的麻醉作用可减轻晚期肿瘤患者的痛苦;②冷冻可避免出血的发生;③冷冻引起肿瘤细胞不可逆坏死,并在坏死组织周围形成一个粒细胞区;④液氮冷冻使机体对肿瘤产生自身免疫反应,可减少肿瘤存活机体对肿瘤产生自身免疫反应,可减少肿瘤存活或复发;⑤与手术…     

Screening for hepatocellular carcinoma

There is currently no evidence that screening patients at risk for hepatocellular carcinoma reduces mortality from the disease. Nonetheless, screening is widely practiced. Screening is a process that includes selecting patients, applying screening tests, deciding on recall policies, and subsequently proving or disproving the presence of cancer. The literature on screening for hepatocellular carcinoma is confusing at best, and does not adequately consider the many biases that result from uncontrolled and retrospective studies. Nonetheless, screening can be justified because it is likely that mortality is decreased by adequate treatment of small cancers, particularly in the era of liver transplantation. False-positive screening test results are common. Once an abnormal screening result is obtained there is little guidance from the literature as to how patients should be investigated further, nor about how to determine whether the screening test result was a false-positive. This should at minimum include short interval follow-up with CT scans and MRI's.     

Screening for hepatocellular carcinoma

BACKGROUND AND AIM: The incidence of hepatocellular carcinoma is high among cirrhotic patients, ranging from 2 to 3% in western cohorts and 6-11% in eastern cohorts. Although only one randomised trial has been performed, clinical practice generally uses periodic screening to detect hepatocellular carcinoma in cirrhotic patients. We reviewed the scientific literature on hepatocellular carcinoma screening. MATERIALS AND METHODS: Evaluation of studies identified through MEDLINE and EMBASE (1990-May 2003). RESULTS: The available screening tests to detect hepatocellular carcinoma are alpha-fetoprotein (cut-off: 20 ng/ml) and ultrasound, which are generally combined. The reported sensitivity and specificity are 50-85% and 70-90%, respectively. An estimated doubling time of about 6 months has led to the use of an interval of 6 months between screenings. Based on the risk of hepatocellular carcinoma, cirrhotic patients are considered as the target population. Screening seems to detect smaller and more frequently unifocal hepatocellular carcinoma; the residual liver function is important for determining the eligibility for effective treatment (resection); hence the prevention is more effective for patients with well-compensated cirrhosis. The survival estimated by non-randomised studies is slightly longer for patients with screening-detected hepatocellular carcinoma, compared to those with clinically detected hepatocellular carcinoma, although few studies have accounted for 'lead time bias'. CONCLUSIONS: Although screening for the early detection of hepatocellular carcinoma has become quite common in clinical practice, its effectiveness remains controversial. Observational studies that have taken into account lead time bias suggest that survival is greater for patients with screening-detected hepatocellular carcinoma, yet the eligibility for effective treatments is low. Considering that only one randomised controlled trial has been conducted, it is crucial to standardise the screening schedule and to evaluate prevention programmes.     

Surgery for hepatocellular carcinoma

Today there is an array of therapeutic modalities available for the patients with hepatocellular carcinoma (HCC). However, surgery, be it resection or transplantation, offers the only hope of long-term disease-free survival. Unfortunately, because the majority of HCC in Asia is associated with cirrhosis, surgical resection is restricted to only a small proportion of these patients. However, in selected candidates resection may offer a 5-year survival of up to 70%. With the clinical application of adult-to-adult living donor liver transplantation, an increasing number of patients with small HCC and decompensating cirrhosis are undergoing transplantation.     

Surveillance for hepatocellular carcinoma

When hepatocellular carcinoma presents with symptoms cure is seldom possible and death usually follows within months. However, it is possible to detect HCC early, at which stage it is curable. This requires a surveillance program. The components of such a program include: identification of the at risk population, provision of appropriate surveillance tests, and an appropriate method of determining whether the abnormalities found on screening are cancer or not. Surveillance for liver cancer meets all these criteria. Unfortunately high quality evidence showing benefit of liver cancer surveillance is lacking, but lesser quality evidence is plentiful, including several cost efficacy analyses that all show that surveillance does decrease mortality. Therefore all the continental liver disease societies and all national liver disease societies have recommended that surveillance should be undertaken.     

Staging for hepatocellular carcinoma

Staging for hepatocellular carcinoma (HCC) has been unsatisfactory for many years. Several staging systems have recently been described. Only one, reported by the Cancer of the Liver Italian Program (CLIP) group, has been prospectively internally validated, and validated externally by retrospective studies. There has been no consensus about which of the several systems is appropriate, nor has any system been widely accepted. Staging systems have been reported by groups from Italy, France, Spain, and Hong Kong, as well as international groups. Staging systems reported from Japan have not been published in the peer-reviewed literature, and are therefore not described. Recently, a consensus conference examined the existing staging systems and recommended a two-part staging process. When initially assessing patients with HCC, the CLIP staging system should be used. For those who undergo surgery, once the pathologic specimen is available a second pathologic staging, as described by the American Joint Committee on Cancer, should be used.     

肝癌诊断标志物研究现状

肝细胞癌（以下称肝癌）全世界发病率不断增高，多数病人确诊时已无法进行手术等有效治疗，故肝癌病人生存率很低。肝硬化是肝癌最大的危险因素，推荐肝硬化病人定期行肝脏超声检查及血清AFP检测。但AFP诊断肝癌灵敏度仅为60％；超声检查则存在操作者依赖性，且鉴别肝硬化再生结节和肝癌灵敏度有限，许多学者试图寻找一种更优的新的肝癌生物标志物。     

Radioembolization for hepatocellular carcinoma

Radioembolization is a form of brachytherapy in which intra-arterially injected (90)Y-loaded microspheres serve as sources for internal radiation purposes. It produces average disease control rates above 80% and is usually very well tolerated. Main complications do not result from the microembolic effect, even in patients with portal vein occlusion, but rather from an excessive irradiation of non-target tissues including the liver. All the evidence that support the use of radioembolization in HCC is based on retrospective series or non-controlled prospective studies. However, reliable data can be obtained from the literature, particularly since the recent publication of large series accounting for nearly 700 patients. When compared to the standard of care for the intermediate and advanced stages (transarterial embolization and sorafenib), radioembolization consistently provides similar survival rates. Two indications seem particularly appealing in the boundaries of these stages for first-line radioembolization. First, the treatment of patients straddling between the intermediate and advanced stages (intermediate patients with bulky or bilobar disease that are considered poor candidates for TACE, and advanced patients with solitary tumors invading a segmental or lobar branch of the portal vein). Second, the treatment of patients that are slightly above the criteria for resection, ablation or transplantation, for which downstaging could open the door for a radical approach. Radioembolization can also be used to treat patients progressing to TACE or sorafenib. With a number of clinical trials underway, the available evidence shows that it adds a significant value to the therapeutic weaponry against HCC of tertiary care centers dealing with this major cancer problem.     

Screening for hepatocellular carcinoma

Screening for hepatocellular carcinoma has become widely practised in the management of patients with end-stage liver disease. However, the theoretical basis for this practice is largely lacking. Issues such as the selection of the target population and the correct method of confirming positive screening tests have yet to be resolved. Complicating the assessment of screening strategies is the poor literature on comparing different forms of therapy. Nonrandomized, uncontrolled studies that do not account for lead-time bias make it frequently impossible to know whether an applied treatment has really improved survival. Despite these difficulties, screening is reality, and strategies have to be devised to efficiently screen patients, find small tumours and apply effective treatments. Some practical strategies are discussed.