肝癌介入治疗的基本原理

1．经导管肝动脉栓塞术（TAE）：肝癌的血供主要来自肝动脉，因此阻断肝动脉可使肝癌血供减少90％以上，使肿瘤坏死，而对正常肝组织影响较少。但肝动脉阻断（结扎）后由于侧支循环建立较快，所以疗效短暂。而使用各种栓塞剂可以阻断肝动脉大部分分支，有效地延缓侧支循环的建立，疗效持久。     

335例中晚期肝癌的肿瘤血供分析及临床应用价值的探讨

１．材料与方法：对３５５例经介入治疗的大肝癌进行回顾性分析,其中,男性２８５例,女性７０例,年龄２５—８０岁,肿瘤大小５—１５ｃｍ,以单一巨块型为多 ;１２５０ ｍＡ数字减影 Ｘ光机; ４Ｆ ＲＨ超滑导管、３Ｆ微导管及相应超导丝。介入术中,首先对肝动脉途径肿瘤供血进行完全栓塞;再观察栓后的肿瘤轮廓是否与ＣＴ、ＭＲＩ的影像相符。如不相符则提示非肝动脉途径的肿瘤供血存在;对于５ ｃｍ以上的肝癌,常规检查隔动脉、肾动脉、肠系膜上动脉等以便找到开放的侧支动脉;对已作过介入治疗的大肝癌则常规找寻侧支动脉。 ２．…     

肝癌动脉化疗栓塞效果的病理评价

目的研究肝细胞癌经动脉化疗栓塞治疗后癌肿的变化，探索提高疗效的方法．方法对动脉化疗栓塞治疗后行手术的３９例肝癌和１１例对照标本进行坏死程度与包膜、治疗次数、病理类型、分化、血管损伤及淋巴细胞浸润诸因素的相关性分析．结果完全坏死者６例，３０％～９５％坏死者１４例，仅５％坏死及无坏死者１９例，１１例ＤＳＡ无坏死．癌肿坏死程度与肿瘤分化、治疗次数、淋巴细胞浸润无关，而与病理类型、包膜、血管损伤有关．结论肝癌动脉化疗栓塞对于有包膜的中晚期肝细胞癌有明显效果．     

肝动脉栓塞化疗结扎与瘤内无水酒精注射治疗中晚期肝癌

目的我们对20例不能手术切除的中晚期肝癌施行肝动脉栓塞化疗结扎与瘤内无水酒精注射,方法简单疗效好.肝动脉结扎(HAL)对肝癌有一定姑息疗效,但HAL后肿瘤的侧支循环4d～14d便恢复到HAL前的血供,未死亡后残存的癌细胞重新分裂,生长更快致治疗失败,为避免HAL后肿瘤侧支循环短时间重新出现,我们用明胶海绵做栓塞剂,同栓塞时做抗癌药物的一次性灌注来提高疗效.肝动脉栓塞结扎主要使肿瘤发生中心性坏死,对肿瘤包膜或包膜外周围的癌浸润缺乏有效控制,酒精注入肿瘤中心与四周后使癌细胞及附近血管内皮等迅速脱水固定,蛋白变性凝固至瘤组织缺血,坏死纤维化,使癌组织、肿瘤被膜及补膜外的周围癌浸润发生凝固性坏死弥补了肝动脉栓塞结扎的不足,20例的疗效结果如下①肿瘤缩小1cm～4cm②生存期延长,为7mo～11mo,平均8.5mo远高于肝癌自然生存期<3mo的报道.③减轻了症状,患者均觉上腹部胀痛基本消失,食欲明显好转,体重增加3kg～6kg.④无1例有腹腔内出血,腹膜炎和肝功衰竭的并发症,对无法手术切除的中晚期肝癌本方法是简单可靠的有效治疗.     

肝动脉栓塞术治疗肝癌的现状

近年来应用肝动脉栓塞术(transcatheter arterial embo1ization,TAE)治疗肝癌引起了人们的重视,现就最近几年来的有关资料作一综述。 TAE治疗的效果肿瘤坏死:70年代后,TAE已逐渐取代了肝动脉结扎术。栓塞术通过阻断肝动脉的血供可使肿瘤的血液供应减少90～95%,而正常肝实质的血供仅降低30～40%,故阻断血流可使肝癌发生缺血性坏死。栓塞术后数周至数月再作动脉造影可见原来栓塞的血管再通,系因造影剂被吸收所致。日本杉田等对140例肝癌采用抗癌剂并栓塞治疗,52.6%以上病例肿瘤缩小达50%以上。     

巨块型肝癌后腹膜侵犯病变的滋养血供来源与经动脉化学治疗栓塞

目的 通过分析巨块型肝癌伴后腹膜侵犯病变的滋养动脉血供来源及数字减影血管造影表现特点,探索完全性阻塞肿瘤血液供应的方法.方法 对75例巨块型肝癌伴后腹膜侵犯病变的患者通过肝动脉途径超选择性动脉插管并行完全性化学治疗栓塞术,对其病变区的碘油沉积与CT或MRI的结果显示不符合者,找寻其潜在的肿瘤滋养动脉并行超选择性插管化学治疗栓塞术,术后行CT或MRI检查以评价治疗效果.结果 75例巨块型肝癌后腹膜侵犯病变患者首次肝癌经导管肝动脉化学治疗栓塞术术前发现14例分支供血,经1～4次肝癌经导管肝动脉化学治疗栓塞术治疗后发现61例分支供血.后腹膜病变大部分或全部由肝外侧支动脉滋养的患者分别为24例、51例.后腹膜病变滋养动脉为右侧膈下动脉后支48例,为右侧肾上腺动脉25例,为右侧第1腰动脉2例.超选择性肿瘤滋养动脉插管成功75例.栓塞术后3～6个月CT复查,病变区碘油完全充填72例、大部分充填3例,病变明显缩小、缩小、变化不明显分别为55例、15例、5例.术后6、12、24、36个月生存人数分别为68、61、37、30例.结论 超选择性插管行肝癌经导管肝动脉化学治疗栓塞术的成功率及安全性高、临床疗效显著,肿瘤滋养动脉完全性充填栓塞可提高患者的生存率及生活质量.     

生物微球联合碘油经肝动脉栓塞化疗治疗原发性肝癌临床观察

目的观察生物微球联合碘油经肝动脉栓塞化疗(TACE)治疗不能手术切除的原发性肝癌患者的临床疗效。方法选择本院2010年1月至2012年12月40例行选择性肝动脉栓塞化疗时使用生物微球联合碘油栓塞化疗的原发性肝癌患者和42例行选择性肝动脉栓塞时使用碘油栓塞化疗的患者,每例行栓塞术4次以上,于首次术后1、3、6、12和24 m随访生存患者肝功能、甲胎蛋白、腹部增强CT等变化,比较治疗后病灶缩小程度,观察肿瘤部分缓解率及患者生存率。结果在首次术后3个月时,微球联合组肿瘤缓解率为(57.44%),明显高于TACE组[(45.23%),P0.05],6个月时微球联合组AFP为(296.7±96.3)ng/ml,明显低于TACE组[(346.9±118.3)ng/ml,P0.05],12个月时微球联合组肿瘤直径为(3.36±1.37)cm,明显低于TACE组[(4.98±1.87)cm,P0.05],24个月时微球联合组生存率为(15.0%),明显高于TACE组[(2.3%),P0.05]。结论生物微球联合碘油栓塞化疗治疗患者病灶缩小程度、AFP下降水平、肿瘤部分缓解率及患者生存率明显高于单纯碘油栓塞化疗组,生物微球联合碘油栓塞化疗治疗中晚期原发性肝癌疗效确切,临床疗效优于单纯栓塞化疗,且安全可行。     

无水乙醇注射联合肝动脉栓塞化疗治疗原发性肝癌患者效果分析

目的探讨无水乙醇注射联合经导管肝动脉栓塞化疗治疗原发性肝癌患者的效果。方法将110例原发性肝癌患者分为治疗组55例和对照组55例。给予对照组经肝动脉化疗栓塞治疗,给予治疗组无水乙醇注射联合经肝动脉化疗栓塞治疗。结果在治疗后3月观察,治疗组肿瘤坏死23例(41.8%),而对照组坏死13例(23.6%),两组之间有显著性统计学差异(P0.05);经随访,治疗组平均生存时间为(21.87±4.23)个月,而对照组为(14.98±5.11)个月(P0.05);治疗后两组肝功能指标的变化无显著性差异(P0.05)。结论无水乙醇注射联合经肝动脉栓塞化疗治疗原发性肝癌能促使肿瘤坏死,减少对于肝功能的损害,从而延长患者生存时间。     

海藻酸钠微球栓塞治疗术后复发性肝细胞癌40例

目的:评价海藻酸钠微球栓塞(kelp micro gelation,KMG)治疗术后复发性肝细胞癌(hepatocellular carcinoma,HCC)的安全性及有效性.方法:回顾性分析2007-06/2007-12以海藻酸钠微球超选择性肝动脉栓塞治疗的40例根治性肝切除术后复发的HCC患者的临床资料,分析其栓塞治疗后并发症、不良反应的发生率与1 mo后肿瘤坏死率,1、2年的总生存率及影响其生存的相关因素.结果:男32例,女8例,平均年龄42岁,总共76个肿瘤结节(直径2.14 cm,平均4.2 cm),从初次栓塞治疗到治疗后2年共计实施了196例次栓塞,每例栓塞治疗2-7次,每次栓塞剂量在0.1-1.2 g.常见的不良反应分别是肝区疼痛(39.8%)、发热(35.2%)和恶心呕吐(34.2%),无严重并发症和治疗相关的死亡发生.初次栓塞后1 mo,复查增强CT或MRI并测量肿瘤坏死率,按照修正的RECIST标准评价:完全坏死13%(10/76),部分坏死47%(36/76),无变化32%(24/76),进展8%(6/76).1年、2年生存率分别是85%、47.5%.结论:海藻酸钠微球栓塞治疗术后复发性HCC安全、有效,可作为复发性HCC栓塞治疗时的新选择.     

肝癌动脉化疗栓塞效果的病理评价

目的研究肝细胞癌经动脉化疗栓塞治疗后癌肿的变化，探索提高疗效的方法。方法对动脉化疗栓塞治疗后行手术的３９例肝癌和１１例对照标本进行坏死程度与包膜、治疗次数、病理类型、分化、血管损伤及淋巴细胞浸润诸因素相关性的分析。结果完全坏死者６例，３０％＿９５％坏死者１４例，仅５％坏死及无坏死者１９例，１１例ＤＳＡ无坏死。癌肿坏死程度与肿癌分化、治疗次数、淋巴细胞浸润无关，而与病理类型、包膜、血管损伤有关。结论肝癌动脉化疗栓塞是中晚期肝癌目前唯一可取的治疗方法。对于有包膜的肝细胞癌，只要治疗能达到癌肿部位，即使一次治疗，也可收到明显的效果。对于如何使每例都达到彻底的癌肿坏死是值得进一步探讨的。     

Superiority of combined chemo-embolization and portal infusion with 5-fluorouracil over locoregional infusion concepts in Novikoff hepatoma-bearing rats

The aim of this study was to investigate experimentally whether there is a superior effect of the combination of hepatic artery chemo-embolization with portal vein infusion over either of the two treatment modalities alone. Novikoff hepatoma cells transplanted under the liver capsule of Sprague Dawley rats were used as a model. Tumor growth was assessed at 7 and 21 days after tumor inoculation. The prolamine solution Ethibloc was employed for embolization, and 5-fluorouracil was used as a chemotherapeutic agent for both infusion and chemo-embolization. All arterial treatment modalities were administered in a super-selective manner. There was no intolerable toxicity after dosages of 55 to 125 mg 5-fluorouracil/kg body weight. With regard to therapeutic efficacy the results show that embolization is an effective therapeutic means for inducing tumor necrosis in selected liver areas. As a consequence, the ranking of all treatment modalities was based on the combined evaluation of tumor size and extent of tumor necrosis. According to this evaluation, hepatic artery chemo-embolization was superior to the respective type of infusion (P<0.01). In addition, the combination of both modalities in the form of hepatic artery chemo-embolization and portal vein infusion was effective in destroying more than 97% of vital tumor tissue (P<0.01). These results suggest the need for a comparative clinical study.     

Resection of a locally advanced hilar tumor and the hepatic artery after stepwise hepatic arterial embolization： A case report

We herein report a case of a hilar tumor with extensive invasion to the proper hepatic artery, which was successfully treated with a radical resection in a 57-year-old female patient after a stepwise hepatic arterial embolization. She underwent right colectomy and partial hepatectomy for advanced colon cancer two years ago and radiofrequency ablation therapy for a liver metastasis one year ago, respectively. A recurrent tumor was noted around the proper hepatic artery with invasion to the left hepatic duct and right hepatic artery 7 mo previously. We planned a radical resection for the patient 5 mo after the absence of tumor progression was confirmed while he was undergoing chemotherapy. To avoid surgery-related liver failure, we tried to promote the formation of collateral hepatic arteries after stepwise arterial embolization of the posterior and anterior hepatic arteries two weeks apart. Finally, the proper hepatic artery was occluded after formation of collateral flow from the inferior phrenic and superior mesenteric arteries was confirmed. One month later, a left hepatectomy with hepatic arterial resection was successfully performed without any major complications.     

Safety of Curcuma aromatica oil gelatin microspheres administered via hepatic artery

AIM: To evaluate the safety of Curcuma aromatica oil gelatin microspheres (CAO-GMS) infused via hepatic artery against primary liver cancer. METHODS: The safety of CAO-GMS was evaluated in view of its acute toxicity in rats, long-term toxicity in Beagle dogs and general pharmacology in rats and mongrel dogs. RESULTS: The 50% lethal dose (LD50) of CAO-GMS infused via the hepatic artery was 17.19 mg/kg, and the serum biochemical indices of dying rats after the administration changed markedly while those of survived rats did not. Subsequent pathological examination of the tissues from the dead rats indicated improper embolism. Similar edema and small necrotic foci in the hepatic lobule were found in the hepatic tissue of rats receiving 10 and 5 mg/kg CAO-GMS and GMS 60 d after the last administration, while not in the rats of the blank control group, indicating that microspheres infused via the hepatic artery may induce irreversible liver damage dose-dependently. General pharmacological study showed that the activities (posture and gait), respiration frequency, blood pressure or heart rate of the dogs were not affected by CAO-GMS, nor were salivation, tremor or pupil changes of the rats observed or their balancing ability compromised, suggesting CAO-GMS infused via the hepatic artery did not significantly affect the nervous, respiratory and cardiovascular systems. CONCLUSION: CAO-GMS embolization administered via the hepatic artery is safe but undesired embolization induced by vascular variation should be given due attention in its clinical application. Individualized embolization dosage and super-selective catheterization technique are recommended to avoid undesired embolism and reduce complications.     

Subsegmental transcatheter arterial embolization for small hepatocellular carcinoma

BACKGROUND/AIMS: The evaluation of long-term outcome of subsegmental transcatheter arterial embolization, which was designed to bring about sufficient anti-tumor effect, in the primary cases of small hepatocellular carcinoma. METHODOLOGY: We analyzed and compared the anti-tumor effect and the survival rate in the primary cases of solitary small hepatocellular carcinoma (< or = 3 cm) with cirrhosis treated by subsegmental transcatheter arterial embolization, chemolipiodolization or percutaneous ethanol injection therapy during the last eight years, retrospectively. RESULTS: The complete tumor necrosis by one session of subsegmental transcatheter arterial embolization, which means that treated tumor showed complete response and did not show local recurrence thereafter, was seen in approximately 50% of the cases. The rate of complete tumor necrosis was superior to that in the patients treated by chemolipiodolization although it was lower than that in the patients treated by percutaneous ethanol injection therapy. Both of the 5- and 7-year survival rates in the patients treated by subsegmental transcatheter arterial embolization were 41.2%. It was slightly higher than those in the other treatment groups without significant difference. CONCLUSIONS: Subsegmental transcatheter arterial embolization might be effectively performed as an initial treatment for the primary cases of the solitary small hepatocellular carcinoma when tumor was fully supplied by hepatic arterial blood regardless of small size.     

Comparative study on the effects of hepatic arterial embolization with Bletilla striata or Gelfoam in treatment of primary hepatic carcinoma

AIM: To study the safety and efficacy of hepatic arterial embolization (HAE) with Bletilla striata powders containing traditional Chinese herbs in the treatment of primary hepatic carcinoma (PHC). METHODS: From May 1990 to September 1993, 106 patients with PHC were treated by HAE with different types of Bletilla striata powders (n = 56) or Gelfoam powders (n = 50) under clearly specified conditions. We analyzed the effects and complications associated with these two types of treatment. RESULTS: The Bletilla striata powders produced extensive and permanent proximal embolization of the hepatic artery, and stimulated the formation of collateral circulation. Treatment could be stopped for as long as 6-12 mo, and there was obvious evidence of tumor necrosis and shrinkage. The patient survival rates at 1, 2, and 3 years were 81.9%, 44.9%, and 33.6%, respectively, and the mean survival time without a serious complication was 19.8 mo. Patients in the Bletilla striata group displayed better clinical effects from their treatment when compared with patients in the Gelfoam group. CONCLUSION: Bletilla striata powders are superior to Gelfoam powders when used for angioembolus in patients with hepatic carcinoma.     

Transcatheter arterial embolization for advanced hepatocellular carcinoma resulting in a curative resection: report of two cases

Transcatheter hepatic arterial embolization and lipiodolization have been reported to be effective palliative treatments for patients with unresectable hepatocellular carcinoma. We experienced 2 patients with advanced hepatocellular carcinoma which were initially considered to be unresectable due to the extreme extension of the primary lesions. Therefore, transcatheter hepatic arterial embolization with lipiodolization were selected as the treatments of choice. Thereafter, these tumors markedly decreased in size and, as a result, curative resections could subsequently be performed. The pathological examination of the resected specimens revealed necrosis and hyaline degeneration in the main tumors. Viable tumor cells, however, still remained adjacent to the main tumors. Such evidence indicated the limited efficacy of transcatheter hepatic arterial embolization with lipiodolization and the necessity of performing surgical treatment in combination with transcatheter hepatic arterial embolization with lipiodolization. Based on these findings, transcatheter hepatic arterial embolization with lipiodolization both appear to be a good mode of therapy for advanced hepatocellular carcinoma, and in selected patients, subsequent surgery can also be considered.     

Transcatheter arterial embolization-induced bilious pleuritis in a patient with hepatocellular carcinoma

A 52-year-old man with hepatocellular carcinoma (HCC) was admitted with cough and fever. He had undergone four series of treatments, including transcatheter embolization and chemoembolization with lipiodol and anticancer drugs, over the previous 2 years. Computed tomography demonstrated dilated hepatic ducts, localized necrosis in the right hepatic lobe, and subphrenic abscess. He died of respiratory failure, because of increased effusion of the right pleura, about 3 weeks after admission. Autopsy revealed adhesions in the lower lobes of the right lung, diaphragm, and liver, with granulomas with bile pigment. A fistula was observed from the necrotic regions of the right hepatic lobe to the pleura through the diaphragm. A tumor thrombus in the portal trunk was histologically confirmed as well and moderately differentiated HCC with trabecular arrangement. Direct invasion of HCC with necrotic tissue to the pleura through the diaphragm appeared to have caused the respiratory failure. Although bilious pleuritis is a rare complication of transcatheter arterial embolization (TAE), it should be considered as an adverse effect of TAE in patients with a dilated hepatic duct.     

Treatment of hepatoma with liposome-encapsulated adriamycin administered into hepatic artery of rats

AIM: To observe the therapeutic effects of liposome-encapsulated adriamycin (LADM) on hepatoma in comparison with adriamycin solution (FADM) and adriamycin plus blank liposome (ADM BL) administered into the hepatic artery of rats. METHODS: LADM was prepared by pH gradient-driven method. Normal saline, FADM (2 mg/kg), ADM BL (2 mg/kg), and LADM (2 mg/kg) were injected via the hepatic artery in rats bearing liver W256 carcinosarcoma, which were divided into four groups randomly. The therapeutic effects were evaluated in terms of survival time, tumor enlargement ratio, and tumor necrosis degree. The difference was determined with ANOVA and Dunnett test and log rank test. RESULTS: Compared to FADM or ADM BL, LADM produced a more significant tumor inhibition (tumor volume ratio: 1.243±0.523 vs 1.883±0.708, 1.847±0.661, P < 0.01), and more extensive tumor necrosis. The increased life span was prolonged significantly in rats receiving LADM compared with FADM or ADM BL (231.48 vs 74.66, 94.70) (P < 0.05). CONCLUSION: The anticancer efficacies of adriamycin on hepatoma can be strongly improved by liposomal encapsulation through hepatic arterial administration.     

Critical collateral bloodflow level for salvage of ischemic myocardium

Twenty-three dogs with occluded coronary arteries were retrospectively analyzed in an attempt to estimate the critical collateral bloodflow for salvaging ischemic myocardium. Under pentobarbital anesthesia a coronary branch was occluded by an embolus. The field of the occluded artery (ischemic zone) was determined by subsequent autoradiography of 141cerium (141Ce) labelled microspheres injected into the left ventricle, 2 to 8 mins after embolization. The regional myocardial bloodflow was also measured by microspheres. Dogs were sacrificed after 24 h (n = 9) or 48 h (n = 14) of coronary occlusion and the data pooled. Size of the necrotic myocardium, determined by tetrazolium staining, was expressed as a percentage of the ischemic zone (percentage necrosis). Percentage necrosis (%N) was negatively correlated with the collateral flow as a percentage of the flow of the corresponding nonischemic layer (%CF) whether the subendocardial, midmyocardial or subepicardial collateral flow was considered. For subendocardium, %N = 81.15 - 3.96%CF and r = -0.77; for midmyocardium, %N = 80.60 - 1.98%CF and r = -0.71; and for subepicardium, %N = 90.23 - 1.03%CF and r = -0.90, all P less than 0.01. Because there is a transmural gradient of the collateral flow in the ischemic zone, the zero necrosis intercept of the regression line of percentage necrosis-subendocardial percentage collateral flow plot would represent the minimal flow level for myocardial survival. This intercept was calculated to be 20.5% normal with a 95% confidence interval between 10.4% and 37.5% (df = 21).(ABSTRACT TRUNCATED AT 250 WORDS)