晚期肝癌患者TAE治疗对肝脏血流动力学的影响

采用彩色多普勒血流显象仪观察肝动脉化疗栓塞术（ＴＡＥ）对原发性肝癌患者肝动脉、门静脉血流速度和血流量的影响。结果显示：ＴＡＥ治疗后肝动脉血流速度、血流量在第１、第３周显著降低，术后第５周基本恢复至术前水平，随着ＴＡＥ治疗次数增加，肝动脉血流量持续减少。ＴＡＥ术后第１、第３、第５周，门静脉血流速度、血流量比术前显著增加，首次ＴＡＥ治疗导致的门静脉血流量增加并不因为ＴＡＥ次数增加而改变。作者认为，为了提高ＴＡＥ治疗效果，术后第５周左右，应再次进行肝动脉栓塞化疗，尽量增加肝癌患者ＴＡＥ治疗次数，除栓塞肝动脉外，还应对门静脉血流进行阻断     

肝细胞癌伴门静脉癌栓不同治疗方法的比较

目的 比较肝细胞癌合并门静脉癌栓(ｔｕｍｏｒ ｔｈｒｏｍｂｉ ｉｎ ｐｏｒｔａｌ ｖｅｉｎ,ＰＶＴＴ）不同治疗方法的疗效及其意义。方法 １４７例肝细胞癌伴门静脉主干或第１分支癌栓的住院患者,按不同治疗方法分成４组：保守治疗组（Ａ组,１８例）;肝动脉结扎和（或）肝动脉插管化疗组（Ｂ组,１８例）,术后定期栓塞化疗;肝癌联同ＰＶＴＴ切除组（Ｃ组,７９例）;手术切除＋肝动脉化疗栓塞和（或）肝动脉置管或门静脉     

肝动脉化疗栓塞对原发性肝癌伴门静脉癌栓的治疗作用

目的:研究肝动脉化疗栓塞(HACE)对原发性肝癌伴门静脉癌栓的治疗作用及影响患者预后的临床病理因素。方法:随访35例HACE治疗的原发性肝癌伴门静脉癌栓患者,其中14例患者经导管肝动脉化疗栓塞,21例患者术中行肝动脉插管,术后经药物泵定期化疗栓塞。单因素分析各临床病理因素对患者预后的影响。多因素分析用Cox比例风险模型。结果:原发性肝癌伴门静脉癌栓行HACE治疗的患者中位生存时间8·3个月,其半年、1和2年生存率分别为57·5%、15·7%和0。单因素分析提示门静脉癌栓部位、化疗栓塞次数是影响患者预后的主要因素。多因素分析仅提示门静脉癌栓部位影响患者的预后。结论:HACE治疗原发性肝癌伴门静脉癌栓可以延长患者的生存期。门静脉癌栓的部位是影响患者预后的独立因素。     

晚期肝癌伴门脉癌栓的介入治疗

对19例晚期肝癌伴门脉瘤柱的介入治疗疗效和肝动脉栓塞的安全性及疗效进行了回顾性分析。结果显示，13例经加用碘油或明胶海绵栓塞肝动脉的病例均有不同程度的肿瘤缩小，在抗癌药物加碘油、明胶海绵栓塞的肝动脉组中，9例门脉显影者仅1例ALT和AST升高，而3例门脉未显影者全部升高。作者认为：对伴有门脉癌栓的晚期肝癌，只要间接门静脉造影显示门静脉，应加用碘油和明胶海绵栓塞肝动脉；但对门脉未显影者，用碘油栓塞较为安全，不宜用明波海绵栓塞。应用该法治疗后，可延长患者的生存期。     

原发性肝癌合并门静脉癌栓的介入治疗进展

门静脉癌栓是导致肝癌远处转移及术后复发的重要因素之一，严重影响肝癌患者预后。针对门静脉癌栓，目前仍缺乏有效手段，介入治疗以其微创、可重复性等优点存临床得到广泛应用．并取得一定的疗效。目前主要应用的介入治疗方法包括：绎导管动脉灌注化疗术、经导管动脉化疗栓塞术、肝动脉、门静脉双途径化疗栓塞术、无水酒精注射术、门静脉支架置放术和超声消融术，多种方法联合治疗有望取得较好疗效。     

肝动脉门静脉双重栓塞术治疗肝癌对肝脏储备功能的影响

１０例原发性肝癌患者经腹脉动脉门静脉双重插管，同时化疗栓塞，并观察了术前术后肝脏储备功能指标的变化。１０例患者的肝实质栓塞率在８．３６％～４７．８％。其中４例接近或超过４０％，血浆中ｃＡＭＰ基础浓度，术前术后相比无显著变化，Ｐ＞０．０５，经胰高血糖素负荷后，ｃＡＭＰ浓度从术前的２７８．３１降至术后的１４２．３８ｐｍｏｌ／ｍｌ，Ｐ＜０．０５，４例术后ｃＡＭＰ明显低下（小于９０ｐｍｏｌ／ｍｌ）；患者术前肝动脉门静脉血流灌注指数与肝硬化时改变相似，８例中２例肝动脉门静脉血流均增加，３例肝动脉血流增加，门静脉减少，另外３例则相反；３例栓塞率较高。负荷后ｃＡＭＰ低下者出现了一过性黄疸和腹水。结果表明：①双重栓塞可损害一部分肝实质，对肝脏储备功能产生一定影响，但尚在代偿范围之内；②双栓范围较大，ｃＡＭＰ低下时注意保护功能；③双栓后肝血流的变化复杂，应进一步研究必手术操作简便，方法可靠安全。     

肝细胞癌合并门静脉癌栓外科治疗的疗效观察

目的探讨肝细胞癌合并门静脉癌栓（PVTT）外科治疗的效果。方法对156例肝细胞癌合并门静脉主干或第一分支癌栓的患者,均行肝癌联同门静脉癌栓切除或取栓,其中94例患者术后行肝动脉和（或）门静脉化疗。结果术后3例死于肝功能衰竭,2例死于术后并发症,余术后恢复良好,术后1、3、5年生存率分别为58．1％（86/148）、18．9％（28／148）、5．4％（8／148）。结论肝切除和门静脉切开取栓术是肝细胞癌合并PVTT的有效治疗方法,术后联合肝动脉和（或）门静脉化疗能提高治疗效果,延长患者的生存期。     

彩超检测血流动力学对原发性肝癌合并门静脉高压及术后复发的临床评估价值

目的 探究彩色多普勒超声检测血流动力学对原发性肝癌合并门静脉高压及术后复发评估的临床价值。方法 选择原发性肝癌合并门静脉高压患者106例作为观察组,选择同期体检健康人100例作为对照组,均采用彩色多普勒超声进行检测。比较2组门静脉、脾静脉血流动力学指标。观察组患者均行手术,术后1年根据是否复发分为复发组及未复发组,比较2组的肝动脉、门静脉血流动力学指标。结果 观察组的门静脉内径、门静脉血流量、脾静脉内径及脾静脉血流量均高于对照组(P<0.05),观察组的门静脉血流速度、脾静脉血流速度速度均低于对照组(P<0.05)。不同门静脉主干内径、脾静脉内径患者的食管胃底静脉曲张程度比较,差异有统计学意义(P<0.05),且随门静脉主干内径及脾静脉内径增加,患者食管胃底静脉曲张程度加重。复发组的肝动脉内径、门静脉内径均较未复发组增粗;复发组的肝动脉血流速度、肝动脉血流量、门静脉血流速度、门静脉血流量、肝动脉血流量/门静脉流量均高于未复发组,差异有统计学意义(P<0.05)。结论 采用彩色多普勒超声检测血流动力学,有助于评估原发性肝癌合并门静脉高压,为临床诊断及治疗提供参考依...     

减量化疗肝动脉栓塞治疗肝癌合并门脉癌栓的研究

目的研究减量化疗肝动脉栓塞治疗伴有门脉癌栓原发性肝癌的安全性及疗效。方法回顾性分析172例经减量化疗肝动脉栓塞治疗的伴有门脉主干和（或）一级分支癌栓的原发性肝癌。其中合并门脉一级分支癌栓者76例,合并门脉主干（包括同时合并门脉一级分支）癌栓者96例。结果 172例肝癌的中位生存期为8.0月,1、2、3年生存率分别为39.5%、22.3%、17.0%。伴有门脉一级分支癌栓与伴有门脉主干癌栓的两组患者平均生存时间差异无统计学意义（18.2月vs 18.5月,P〉0.05）;两组1、2、3年生存率差异无统计学意义（39.1%、15.7%、13.7%vs 39.8%、29.3%、20.3%,P〉0.05）。单因素及多因素生存分析显示,肿瘤大小及AFP水平是生存时间的影响因素。172例患者共行377次介入,无消化道大出血、肝功能衰竭、肺栓塞等严重并发症。结论减量化疗肝动脉栓塞治疗伴有门脉癌栓的原发性肝癌是安全有效的。     

肝癌合并门静脉癌栓的诊治进展

门静脉癌栓是影响肝癌患者预后的最重要因素之一.文章系统回顾了门静脉癌栓的形成机制、诊断及治疗方面的进展.虽然癌栓可通过影像学检查(尤其是术中B超)得以发现,但癌栓治疗效果一直不能令人满意.术中肿瘤切除加门静脉取栓、加术后肝动脉、门静脉双灌注化疗等综合治疗是目前应用较多的疗法.     

Anticancer effect of UFT in intrahepatic recurrence with tumor embolus in the left portal vein after hepatectomy of hepatoma--a case report

A 65-year-old man was diagnosed as having hepatoma (HCC) in the area of S5 and S8. Anterior segmentectomy was performed on September, 1984. TAE (Sandwich therapy) via r. hepatic artery was performed for the intrahepatic recurrence one and half years after hepatectomy. However, the tumor embolus in the l. portal vein with intrahepatic recurrence occurred, and intraarterial infusion chemotherapy (IAC) using CDDP 150 mg was performed via proper hepatic artery. The decrement of AFP value was observed for a short time after IAC therapy. Therefore, UFT 300 mg daily, was administered. For two and half months after UFT administration, the elevation of AFP value continued from 665 ng/ml to 4150 ng/ml, and decreased rapidly below 20 ng/ml in the following 2 months. The tumor embolus in the l. portal vein was remarkably reduced on computed tomogram examination. This case suggests the usefulness of UFT for the intrahepatic recurrence with tumor embolus in the portal vein after hepatectomy for HCC.     

Pharmacokinetics of 5-fluorouracil following different routes of intrahepatic administration in the canine model

In an effort to achieve high concentrations of 5-fluorouracil (5-FUra) in the hepatic circulation while minimizing systemic exposure, several routes of intrahepatic administration were compared in the canine model. To ascertain these data, 5-FUra (30 mg/kg) was given as a bolus into either a systemic vein (femoral vein), hepatic artery, hepatic artery distal to its ligation after hepatic dearterialization, or through the portal vein. Three dogs were studied for each route with concomitant blood samples taken from the inferior vena cava and hepatic vein at 1, 2, 3, 5, 10, 15, 30, and 60 min after injection. 5-FUra levels were determined in plasma by high-pressure liquid chromatography. Blood flow in the portal vein and hepatic artery was measured by an electromagnetic flowmeter. The data were best described by a multicompartmental model including the measured flows. Hepatic components of the model were separate arterial and portal compartments, with elimination from each described by linear kinetics. Analysis of the results indicated that the highest hepatic levels with the least systemic exposure, as indicated by drug levels in hepatic and peripheral vein, were realized following hepatic artery administration distal to its ligation after hepatic dearterialization.     

Influence of the routes of continuous intrahepatic infusion of 5-fluorouracil on its pharmacokinetics

Continuous infusion chemotherapy via hepatic artery using newly available mechanical devices is frequently used to treat hepatic metastases to achieve a high concentration of 5-fluorouracil (5-FUra) in the hepatic circulation while minimizing systemic exposure. We compared four routes of intrahepatic administration to find out the best one in the canine model. To ascertain this data, 5-FUra (30 mg/kg) was given as a continuous infusion over a 3 hr period into either a systemic vein (femoral), portal vein, hepatic artery, or hepatic artery distal to its ligation after hepatic dearterialization. A total of eight dogs were studied. During 5-FUra infusion, concomitant blood samples were taken from the inferior vena cava and hepatic vein at 1, 2, 3, 5, 10, 15, 30, 60, 120, and 180 min. 5-FUra levels were determined in plasma by high-performance liquid chromatography. Blood flow in the portal vein and hepatic artery was measured by an electromagnetic flowmeter. The data described by a multicompartmental model, including the measured flows, had separate hepatic arterial and portal compartments with elimination from each described by linear kinetics. Mean area under the curve values in microgram/ml X min and the ratios of the systemic/hepatic vein areas following 5-FUra infusion via systemic, portal vein, hepatic artery, or hepatic artery after dearterialization routes were: 975/539 (R = 1.80), 939/748 (R = 1.35), 211/454 (R = 0.46), and 562/1,424 (R = 0.39). The results indicated that the administration of 5-FUra via the hepatic arterial route distal to its ligation results in the highest hepatic vein drug levels with the smallest systemic/hepatic vein exposure ratio, followed by intra-arterial route, while systemic and portal vein routes were not nearly as advantageous as the intra-arterial routes.     

Intrahepatic arterial flow distribution after ligation of a right replaced hepatic artery. A case report

A basic requirement for arterial chemotherapy of liver tumors is complete catheter perfusion of the liver. In cases with atypical anatomy of the hepatic artery, it is frequently impossible to obtain this goal by means of a single catheter. In a patient with a right replaced hepatic artery, the aberrant vessel was ligated and the left hepatic artery was perfused through a catheter inserted into the gastroduodenal artery. Perfusion scans performed through the catheter 14 and 135 days after arterial ligation showed a fall in the arterial flow to the right liver (right/left ratio 0.43 and 0.60). In contrast, a nearly complete perfusion of the liver (0.91 right/left ratio) was obtained 28 days after ligation, when the perfusion scan was performed immediately after catheter infusion of 90,000,000 degradable starch microspheres (DSM: diameter = 40 m). DSM administration is supposed to increase back pressure in the lobe receiving native circulation, thus activating intrahepatic collateral flow to the ischemic lobe. As regards regional treatment of liver tumors, obvious conclusions are to be drawn.     

晚期肝癌肝脏内外侧支供血及临床意义

目的：探讨肝癌肝脏内、外侧支供血的产生机理。方法：收集TAE治疗资料完整的中晚期肝癌340例，对其血管造影表现进行分析。结果：肝内侧支供血227例：叶间侧支207例，叶内侧支20例；肝外侧支供血78例：胃左肝在动脉共干21例、网膜动脉29例、右IPA13例、左IPA5例、结肠中动脉9例、右肾动脉1例；肝内合并肝外侧支同时供血35例。结论：侧支供血形成的机制与肝脏的解剖及肿瘤生长部位有关。认为了解肿瘤侧支供血的造影表现，对肝癌TAE及手术治疗有重要的临床意义。     

碘化油阿霉素肝动脉及门静脉支分期栓塞治疗原发性肝癌

Despite recent advances in hepatic surgery, management of unresectable carcinoma of the liver is still a challenging problem. From September 1988 through March 1989, 10 primary liver cancer patients were treated by hepatic artery embolization (HAE) using lipiodol-adriamycin with or without hepatic artery ligation (HAL). One of them received HAE twice in seven weeks. In two of these patients, following right HAE and HAL, right portal vein embolization (PVE) by catheterization via the ileac vein was performed. Transcatheter portal vein embolization via the ileac vein was simple, easy and safe even it was impossible to expose the hepatic hilum. All patients are alive from 7 to 12 months after operation except one who died of hepatic failure after having survived for 54 days. There was marked alleviation of symptoms and tumor shrinkage was observed in 9 out of 10 patients. HAE and PVE using lipiodol-adriamycin may have the potential of improving the therapeutic effect in patients with hepatocellular carcinoma.     

门静脉右支结扎及肝动脉右支置管治疗巨大右肝癌2例及文献复习

目的：探讨不可切除巨大肝癌的有效治疗手段。方法：对两例巨大右肝癌患者施行门静脉右支结扎和肝右动脉结扎并置管栓塞化疗，比较术前术后甲胎蛋白变化情况和复查肝脏CT片结果。结果：两例患者自觉症状术后均迅速消失。病例1AFP由术前45ng／L，在术后1月降为2ng／L，胆红素及转氨酶曾一过性轻度升高，出现少到中量腹水，未处理自行消退。病例2术前AFP为大于1000ng／L，术后1周降为700ng／L，转氨酶最高354IU／L，胆红素最高231μmol／L，大量腹水，经积极处理后恢复。CT扫描结果显示原肿瘤位置被液性暗区替代。结论：门静脉右支结扎和肝右动脉结扎并置管栓塞化疗是治疗巨大右肝癌有效的方法，效果确切。费用低。     

The effect of portal venous flow on the washout of a regionally injected marker substance 99mTc-methylene diphosphonate after hepatic arterial blockade with degradable starch microspheres.

Patients with hepatic metastases derived from colorectal carcinoma have a poor prognosis. Regional chemotherapy, either alone, or combined with agents such as degradable starch microspheres (DSM) that reduce or abolish intrahepatic arterial flow and potentiate the delivery of cytotoxics to hepatic metastases, have not significantly improved survival. We have investigated one positive mechanism, namely the effect of portal venous washout of cytotoxics, for the poor efficacy of drugs administered either alone or in combination with DSM via the hepatic artery in the rat. Using a radiolabelled marker, 99mTc-methylene diphosphonate (MDP), to represent a cytotoxic drug, the initial studies indicated that with the hepatic artery and portal vein clamped, a volume of 0.05 ml of the marker administered via the hepatic artery resulted in the most uniform intrahepatic distribution with minimal washout into the systemic circulation (21 +/- 3.7%). When the hepatic artery was clamped, the washout of MDP was reduced from 100% (with clamps on the portal vein and hepatic artery) to 84.2 +/- 7.7%. DSM administered concomitantly with MDP, resulted in a greater reduction of the portal venous washout of the marker (63 +/- 2.4%). Administration of DSM and MDP via the hepatic artery and with the portal vein clamped further reduced the washout of the marker to (21 +/- 2.26), results similar to those observed with inflow vessel clamps. Following restoration of portal venous flow, there was a rapid washout of 53.7 +/- 7.6% of the marker into the systemic circulation. The results of this study suggest that portal venous washout of regionally delivered cytotoxics, either alone or in combination with DSM, offer an explanation for the poor efficacy of regional chemotherapy in improving the prognosis of patients with hepatic metastases.     

Changes in hepatic blood flow during regional hyperthermia

The influence of liver hyperthermia on hepatic arterial and portal venous blood flow to tumour and normal hepatic tissue was examined in a rabbit VX2 tumour model. Hyperthermia was delivered by 2450 MHz microwave generator to exteriorized livers in 18 rabbits. Blood flow was measured in both portal vein and hepatic artery using radioactive tracer microspheres before, during and 5 min after intense (>43°C) hyperthermia. During hyperthermia a decrease in total liver blood flow was composed primarily of a decrease in hepatic arterial blood flow to tumour tissue. Tumours were supplied almost exclusively by the hepatic artery and thus total tumour blood flow was significantly depressed during heating. The decreased tumour blood flow persisted after the cessation of hyperthermia and was indicative of vascular collapse in the tumour tissue. Temperature differentials in tumour compared to normal tissue ranged from 5°C to 8°C during hyperthermia because of the lower tumour blood flow. The portal vein exerted minimal influence on temperatures attained in the tumour tissue during hyperthermia but would have mediated normal liver tissue heat loss.     

Changes in hepatic blood flow during regional hyperthermia

The influence of liver hyperthermia on hepatic arterial and portal venous blood flow to tumour and normal hepatic tissue was examined in a rabbit VX2 tumour model. Hyperthermia was delivered by 2450 MHz microwave generator to exteriorized livers in 18 rabbits. Blood flow was measured in both portal vein and hepatic artery using radioactive tracer microspheres before, during and 5 min after intense (greater than 43 degrees C) hyperthermia. During hyperthermia a decrease in total liver blood flow was composed primarily of a decrease in hepatic arterial blood flow to tumour tissue. Tumours were supplied almost exclusively by the hepatic artery and thus total tumour blood flow was significantly depressed during heating. The decreased tumour blood flow persisted after the cessation of hyperthermia and was indicative of vascular collapse in the tumour tissue. Temperature differentials in tumour compared to normal tissue ranged from 5 degrees C to 8 degrees C during hyperthermia because of the lower tumour blood flow. The portal vein exerted minimal influence on temperatures attained in the tumour tissue during hyperthermia but would have mediated normal liver tissue heat loss.