肝癌合并门静脉癌栓的研究进展

<正>肝细胞癌(hepatocellular carcinoma,HCC)是成年人最常见的恶性肿瘤之一,在发展中国家发病率最高,由于其术后高复发和高转移率,预后不佳,每年因肝癌死亡人数仍高居世界恶性肿瘤致死率的第3位[1-2]。HCC预后不佳的一个重要原因是肿瘤侵犯门静脉并形成门静脉癌栓(portal vein tumor thrombosis,PVTT),且肝癌患者PVTT形成发生率很     

肝癌合并门静脉癌栓的治疗方法及价值

门静脉侵犯是肝癌重要的生物学特性,临床报道门静脉癌栓（PVTT）发生率为44．0％～62．2％。PVTT是肝癌肝内播散及根治性切除术后早期复发的根源;此外,癌栓阻塞门静脉,加剧门脉高压,继而引发食道胃底静脉破裂出血,甚至肝功能衰竭。因此,肝癌合并PVTT患者总体预后差,中位生存期仅3～6个月。近年来,国内外学者对肝癌合并PVTT的治疗进行积极探索,取得了一些进展。     

肝癌合并门静脉癌栓的研究进展

肝细胞癌(hepatocellular carcinoma,HCC;以下简称"肝癌")是世界上常见的恶性肿瘤之一,在我国已成为位列第2位的癌症杀手。文献和复旦大学中山医院肝癌研究所(以下简称"我所")资料均提示,肝癌各种疗法的5年生存率都已接近其高限,瓶颈主要是转移复发[1]。肝癌侵犯门静脉形成门静脉癌栓(portal vein tumor thrombus,PVTT)并导致肝内播散是其主要原因之一。根据尸检和影像学及病     

肝细胞肝癌合并门静脉癌栓的诊断及治疗

肝内播散和远处转移是肝细胞肝癌（HCC）治疗困难和死亡的主要原因。门静脉癌栓（PVTT）是导致肝细胞肝癌肝内播散、远处转移及术后复发的最重要因素。早期明确诊断肝细胞肝癌合并门静脉癌栓并给予积极有效的治疗将有利于降低HCC患者术后复发转移率．从而提高HLC患者的总体生存率。     

肝癌合并门静脉癌栓的外科处理

目的：研究肝细胞肝癌合并门静脉癌栓患者外科治疗的效果及影响因素。方法：对３１例肝癌合并门静脉主干及其大分支癌栓患者在电凝锐性解剖肝门的基础上,采用肝叶切除加癌栓清除、门静脉主干切开取栓等术式治疗,并对癌栓的临床病理学类型进行探讨。结果：与非治疗者相比,外科治疗明显延长了患者的术后生存期,疗效最好的方法是肝叶切除加取栓术,１８例术后平均存活时间１５个月,门静脉主干切开取栓术次之,８例平均存活８个月。所有取栓成功的患者术后均无食管静脉曲张破裂出血。癌栓的病理类型以增殖型最多见,机化型罕见,但由于癌栓与门静脉壁紧密粘连,不易清除,后者不宜外科治疗。结论：外科治疗有效地防止了肝癌合并门静脉癌栓的严重并发症──急性上消化道出血,并延长、改善了患者的生存期和生命质量。     

肝细胞癌合并门静脉癌栓的手术切除及疗效观察

目的 探索肝细胞癌合并门静脉癌栓（ＰＶＴＴ）手术切除的疗效及其影响预后因素。方法 总结近１０年１１１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左或右支癌栓切除或经左、右支断端取栓或切开主干取栓,其中２２例患者切除肿瘤及癌栓后行肝动脉和（或）门静脉插管。３２例患者术后经肝动脉化疗栓塞和（或）经门静脉导管化疗。另１４例ＰＶＴＴ患者仅行保守治疗（非手术组）,２０例ＰＶＴＴ患者行探查     

肝细胞癌合并门静脉癌栓外科治疗进展

新理念、新技术、新药物正在改变肝癌的治疗模式,尤其对争议较大的中晚期肝癌病人。外科治疗门静脉癌栓（PVTT）一直备受争议,但现有证据表明外科治疗病人获益最大。当前,PVTT的外科治疗日益规范精准。肝癌新辅助治疗、辅助治疗、转化治疗的应用势必会提升肝癌合并PVTT的外科治疗空间,从而推动肝癌整体诊治水平的提高。     

肝癌合并门静脉癌栓的临床病理分级及意义

目的 评价肝细胞癌（HCC）合并门静脉癌栓（PVTT）临床病理分型在外科治疗HCC合并PVTT中的意义和价值。方法 42例HCC合并PVTT病人，按门静脉主干及其一级分支受累情况、以及有无肝外淋巴结转移将PVTT分为Ⅴ级：Ⅰ级为门静脉一级分支，即门静脉左或右干（LPV、RPV）有瘤栓；Ⅱ级LPV或RPV加门静脉主干（TPV）被侵犯；Ⅲ级LPV、RPV和TPV均受累；Ⅳ级为Ⅲ级加脾静脉或肠系膜上静脉被累及；Ⅴ级为Ⅰ～Ⅳ任何级加肝外组织或淋巴结转移。外科治疗包括肝叶切除加癌栓清除（33例）、门静脉主干切开取栓（9例）等。病理上对30例癌栓行组织学分型，并对其影像学、大体解剖特征和临床经过进行对比分析。结果 癌栓分级Ⅰ到Ⅴ级的例数分别为14、12、11、2和3例，术后中位存活时间分别是28、17．5、7、6、6个月。30例PVTT病理分型增殖型50％、坏死型36．7％、机化型13．3％。4例机化型癌栓手术无法彻底清除，预后不良。结论 本项研究的结果提示：（1）HCC合并PVTT临床病理分型有助于判断预后，Ⅲ级以上病人预后不良，尤其是机化型PVYY。（2）合理选择外科治疗方法，Ⅰ、Ⅱ级宜外科手术，Ⅲ级合并急性上消化道大出血者，可行主干切开取栓术。其余应以综合治疗为主，一般不宜手术治疗。此外，机化型PVTT、在Ⅱ级以上不宜切除治疗。（3）PVTT的外科治疗要强调无瘤原则，尽量避免癌栓术中扩散。     

非规则性肝切除及癌栓取除术治疗肝癌合并门静脉癌栓

目的 探讨非规则性肝切除及癌栓取除术治疗肝细胞癌（ＨＣＣ）合并门静脉癌栓（ＰＶＴＴ）的价值。方法 １９８７年１月至１９９６年１２月采用非规则性肝切除及癌栓取除术治疗ＨＣＣ合并ＰＶＴＴ的病人６２例。其中，４０例在术后联合肝动脉化疗（ＨＡＣ）和门静脉化疗（ＰＶＣ）。５９例随访３年以上。结果 ６例在术后３个月内死于肝、肾功能衰竭，５６例术后恢复良好。术后１、２、３年的复发率和生存率。在手术后应用ＨＡＣ和ＰＶＣ组分别为４６．２％、５９．０％、７９．５％和６９．２％、５１．３％、３０．８％。在未化疗组分别为８０．０％、９０．０％、１００％和３０．０％、１０．０％、５．０％。结论 非规则性肝切除和癌栓取除术是ＨＣＣ合并ＰＶＴＴ有效的治疗方法。术后联合ＨＡＣ和ＰＶＣ可降低复发率、提高生存率。     

肝细胞癌合并门静脉癌栓东西方治疗差异

<正>肝细胞癌(hepatocellular carcinoma,HCC)是一种全球范围内常见且死亡率较高的恶性肿瘤。由于肝脏解剖结构特点以及HCC侵袭转移能力强,癌细胞易侵犯门静脉形成门静脉癌栓(portal vein tumor thrombus,PVTT)。有文献指出大约44%～62.2%的HCC患者合并PVTT^[1]。HCC患者一旦合并PVTT,病情迅速进展,预后极差。PVTT的分型与患者预后息息相关,针对PVTT分型标准主要是中国程氏分型和日本肝癌研究学会的分型^[2,3],西方尚未形成完整的分型体系。目前,东西方对HCC合并PVTT的治疗策略有很大不同。西方指南认为,PVTT是疾病晚期的标志,治愈希望渺茫,推荐系统抗肿瘤治疗作为一线治疗方法^[4-6]。而包括中国在内的东方临床实践指南推荐对部分严格选择的HCC合并PVTT患者进行更积极的抗癌治疗,包括手术切除、放疗、经动脉化疗栓塞等其他治疗^[7]。本文结合国内外HCC诊疗指南及临床实践,对HCC合并PVTT东西方治疗差异做一简介...     

Clinical significance of removal of tumor thrombi in the main portal vein in patients with hepatocellular carcinoma

Twenty-two patients with portal vein tumor thrombi secondary to hepatocellular carcinoma were studied to evaluate the effectiveness of diagnostic and treatment procedures. B-mode ultrasonography is a simple and accurate means for the detection of tumor thrombus in the portal vein. All of the 22 patients were correctly diagnosed by this method, which should be used as the initial screening procedure in such patients. Fourteen of the 22 patients underwent surgical procedures, including embolectomy from the portal trunk; removal of the tumor thrombi combined with hepatectomy or through the rechanneled umbilical vein; and operative transcatheter arterial chemotherapy. The other 8 patients were treated by transcatheter arterial embolization or were not treated. The surgical treatment effectively prevented acute variceal bleeding in the patients who underwent the procedures successfully. The mean value of the portal venous pressure was reduced from 46 cmH₂O to 32 cmH₂O after the surgery. As a result of the effective portal decompression, the patients in the surgical group had a better prognosis and longer mean survival than the others. Our study suggests that portal vein tumor thrombus is not an absolute contraindication for surgery, and that accurate detection and prompt treatment are the keys to the achievement of better clinical results.     

A new staging system for hepatocellular carcinoma associated with portal vein tumor thrombus

BackgroundA new staging system for patients with hepatocellular carcinoma (HCC) associated with portal vein tumor thrombus (PVTT) was developed by incorporating the good points of the BCLC classification of HCC, and by improving on the currently existing classifications of HCC associated with PVTT.MethodsUnivariate and multivariate analysis with Wald χ² test were used to determinate the clinical prognostic factors for overall survival (OS) in patients with HCC and PVTT in the training cohort. Then the conditional inference trees analysis was applied to establish a new staging system.ResultsA training cohort of 2,179 patients from the Eastern Hepatobiliary Surgery Hospital and a validation cohort of 1,550 patients from four major liver centers in China were enrolled into establishing and validating a new staging system. The system was established by incorporating liver function, general health status, tumor resectability, extrahepatic metastasis and extent of PVTT. This staging system had a good discriminatory ability to separate patients into different stages and substages. The median OS for the two cohorts were 57.1 (37.2–76.9), 12.1 (11.0–13.2), 5.7 (5.1–6.2), 4.0 (3.3–4.6) and 2.5 (1.7–3.3) months for the stages 0 to IV, respectively (P<0.001) in the training cohort. The corresponding figures for the validation cohort were 6.4 (4.9–7.9), 2.8 (1.3–4.4), 10.8 (9.3–12.4), and 1.5 (1.3–1.7) months for the stages II to IV, respectively (P<0.001). The mean survival for stage 0 to 1 were 37.6 (35.9–39.2) and 30.4 (27.4–33.4), respectively (P<0.001).ConclusionsA new staging system was established which provided a good discriminatory ability to separate patients into different stages and substages after treatment. It can be used to supplement the other HCC staging systems.     

合并门静脉血栓形成的肝细胞癌肝移植12例分析

目的探讨合并门静脉血栓形成(PVT)的肝细胞癌肝移植手术疗效、手术技巧及围手术期处理。方法回顾性分析中山大学附属第三医院自2003年10月至2005年6月12例合并PVT的肝细胞癌肝移植临床及随访情况。结果术后随访8d至36个月,中位时间19.5个月。术后第12天、第21天、第30天各死亡1例,死于肺部感染、多器官功能衰竭。随访期间死亡1例(术后第15个月死于肝癌复发)。目前存活8例,其中7例已经无瘤生存13、14、24、24、25、28、30个月,1例带瘤存活36个月。12例病人1年累积存活率75.0%。1例病人肝移植术后2个月吻合口局部PVT复发,目前已经存活30个月。结论合并PVT的肝细胞癌肝移植者预后良好,合理的手术技巧和恰当的术后处理可以避免术后PVT复发。     

对比TACE联合125I粒子与联合仑伐替尼治疗肝细胞癌伴门静脉癌栓的有效性及安全性

目的 对比TACE联合¹²⁵I粒子植入或仑伐替尼治疗肝细胞癌(HCC)伴门静脉癌栓(PVTT)的有效性及安全性。方法 回顾性分析52例HCC伴Ⅱ/Ⅲ型PVTT患者,分为TACE联合¹²⁵I粒子组(A组,n=27)及TACE联合仑伐替尼组(B组,n=25);比较2组客观缓解率(ORR)、总生存期(OS)及不良反应率。结果A组ORR、中位OS、Ⅱ型PVTT中位OS及Ⅲ型PVTT中位OS分别为70.37%(19/27)、13.6个月、14.1个月及13.2个月;B组分别为32.00%(8/25)、11.3个月、12.3个月及10.4个月;A组上述指标均优于B组(P均<0.05)。A组不良反应发生率为48.15%(13/27),均未见严重并发症;B组不良反应发生率为88.00%(22/25),5例(5/25,20.00%)出现严重药物毒性反应。结论 TACE联合¹²⁵I粒子治疗HCC伴PVTT的有效性及安全性均优于TACE联合仑伐替尼。     

门静脉灌注化疗治疗肝癌伴门静脉瘤栓的临床价值

目的 探讨肝细胞肝癌伴门脉癌栓（tumor thrombi in portal vein,PVTT)外科手术后，门静脉灌注化疗的价值。方法 45例伴门脉主干或I级分支癌栓的肝癌病人，在行手术切除后随机分组，一组行肝动脉化疗，同时行门静脉灌注化疗（治疗组），另一组仅行肝动脉化疗（对照组）。结果 治疗组6，12，18个月生存率分别为85.1%,76.5%和47.2%。对照组为73.3%，59.2%和33.4%，两组比较差异均有显著性（P＜0.05)。结论 肝癌伴PVTT，手术切除术后，为防治门脉癌栓导致肝内转移复发，术中除应尽量取净癌栓组织外，门脉灌注化疗是有效的措施之一。     

原发性肝癌合并门静脉癌栓86例治疗体会

目的探讨肝癌合并门静脉癌栓(PVTT)的有效治疗方法。方法 86例肝癌合并门静脉癌栓患者行肝切除+门静脉取栓+肝动脉、门静脉双灌注化疗栓塞及生物靶向治疗。结果 1年生存率为90%,2年生存率为85%,3年生存率为35%;结论肝切除+门静脉取癌栓+肝动脉、门静脉双灌注化疗栓塞+生物靶向治疗是治疗肝癌合并门静脉癌栓的有效治疗方法。     

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.     

Successful resection of cholangiocellular carcinoma with tumor thrombus in the main trunk of the portal vein

A space-occupying lesion in the right hepatic lobe, with dilated peripheral bile ducts, was observed by ultrasonography and computed tomography in a 50-year-old man with right upper quadrant abdominal pain. One month later, this lesion evidenced rapid growth and a tumor thrombus, which completely occluded the main trunk and the left primary branch of the portal vein, had developed. The tumor was diagnosed as a cholangiocellular carcinoma with an unusual pattern of intravascular extension. The primary tumor and the portal tumor thrombus were resected via a right hepatic trisegmentectomy combined with resection of the portal vein and extrahepatic bile duct, using a superior mesenteric vein—left femoral vein catheter bypass (SMV—FV bypass). The SMV—FV bypass was found to effectively reduce intraoperative hemorrhage.     

A new classification for hepatocellular carcinoma with hepatic vein tumor thrombus

BackgroundHepatic vein tumor thrombus (HVTT) is a significant poor risk factor for survival outcomes in hepatocellular carcinoma (HCC) patients. Currently, the widely used international staging systems for HCC are not refined enough to evaluate prognosis for these patients. A new classification for macroscopic HVTT was established, aiming to better predict prognosis.MethodsThis study included 437 consecutive HCC patients with HVTT who underwent different treatments. Overall survival (OS) and time-dependent receiver operating characteristic (ROC) curve area analysis were used to determine the prognostic capacities of the new classification when compared with the different currently used staging systems.ResultsThe new HVTT classification was defined as: type I, tumor thrombosis involving hepatic vein (HV), including microvascular invasion; type II, tumor thrombosis involving the retrohepatic segment of inferior vena cava; and type III, tumor thrombosis involving the supradiaphragmatic segment of inferior vena cava. The numbers (percentages) of patients with types I, II, and III HVTT in the new classification were 146 (33.4%), 143 (32.7%), and 148 (33.9%), respectively. The 1-, 2-, and 3-year OS rates for types I to III HVTT were 79.5%, 58.6%, and 29.1%; 54.8%, 23.3%, and 13.8%; and 24.0%, 10.0%, and 2.1%, respectively. The time-dependent-ROC curve area analysis demonstrated that the predicting capacity of the new HVTT classification was significantly better than any other staging systems.ConclusionsA new HVTT classification was established to predict prognosis of HCC patients with HVTT who underwent different treatments. This classification was superior to, and it may serve as a supplement to, the commonly used staging systems.     

Neoadjuvant radiotherapy for resectable hepatocellular carcinoma with portal vein tumor thrombus: a systematic review

BackgroundThe prognosis of hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT) is extremely poor. The clinical outcome of preoperative radiotherapy (RT) is still controversial. This study aimed to compare the clinical outcomes of combined neoadjuvant RT and hepatectomy with hepatectomy alone for HCC with PVTT.MethodsComprehensive database searches were performed in PubMed, the Cochrane Library, EMBASE, and the Web of Science to retrieve studies published from the database creation to July 1, 2020. Only comparative studies that measured survival between neoadjuvant RT followed by hepatectomy and hepatectomy alone were included. The characteristics of the included studies and patients were extracted, and the included data are presented as relative ratio (RR) estimates with 95% confidence intervals (CIs) for all outcomes. The RRs of each study were pooled using a fixed or random effects model with Review Manager (the Cochrane Collaboration, Oxford, UK) version 5.3. The response rate to RT and the overall survival (OS) rate in neoadjuvant RT followed by hepatectomy and hepatectomy alone were measured.ResultsOne randomized and two non-randomized controlled trials with 302 patients were included. Most patients were classified as Child-Pugh A, and Type II and III PVTT were the most common types. After RT, 29 (22.8%) patients were evaluated as partial response (PR) and had a positive RT response, but nine (7.1%) had progressive disease (PD). Neoadjuvant RT followed by hepatectomy was received by 127 (42.1%) patients after excluding 15 (5.0%) patients with severe complications or PD after RT, and 160 (53.0%) patients received hepatectomy alone. In the randomized controlled trial (RCT), the 1-year OS rate in the neoadjuvant RT group and the surgery alone group was 75.2% and 43.1%, respectively (P<0.001). In the two non-randomized studies, a meta-analysis with a fixed effects model showed a longer OS in patients undergoing neoadjuvant RT followed by hepatectomy compared with hepatectomy alone at 1-year follow-up (RR =2.02; 95% CI: 1.45–2.80; P<0.0001).ConclusionsThis systematic review showed that neoadjuvant RT followed by hepatectomy in patients with resectable HCC and PVTT was associated with a longer OS than patients who received hepatectomy alone.