腹腔镜结直肠癌切除术联合射频消融治疗肝转移癌

目的 探讨腹腔镜结直肠癌切除术+同期RFA治疗肝转移癌的临床价值.方法 2001年12月至2006年7月成都市第三人民医院对22例结直肠癌合并同时性肝转移的患者施行腹腔镜结直肠癌切除术+同期RFA治疗肝转移癌,术后通过增强CT检查评价消融灶固化效果.采用X2检验分析疗效.结果 本组22例患者中8例肝转移癌为多发,16例有合并症.对31个肝转移癌进行RFA治疗,未发生相关并发症;术后平均住院时间为(14±5)d,无手术死亡.5例因消融不完全进行重复RFA,4例消融灶复发(2例重复RFA);6例死亡(2例死于消融灶复发).消融灶复发率为18%(4/22),病死率为27%(6/22).肝转移癌直径≥2.0 cm者RFA后消融灶复发率高于直径＜2.0 cm者(x2=5.867,P＜0.05).结论 腹腔镜结直肠癌切除术+同期RFA治疗肝转移癌,为多发性肝转移癌、合并基础疾病、高龄、手术耐受差和肿瘤切除困难的结直肠癌患者提供了治疗的机会.     

Long-term survival following radiofrequency ablation of colorectal liver metastases: A retrospective study

AIM: To retrospectively evaluate the long-term survivalof patients that received radiofrequency ablation(RFA) therapies of colorectal liver metastases. METHODS: In 2005 to 2008, RFA of 105 colorectal liver metastases(CRLM) were performed on 49 patients in our institution. The liver metastases were evaluated, both before and after ablation therapies, with contrast enhanced computerised tomography and contrast enhanced ultrasonography. Histological evidence of malignant liver metastases was obtained in the few instances where contrast enhanced ultrasonography gave equivocal results. Accesses to the CRLM were guided ultrasonically in all patients. The data obtained from records of these ablations were retrospectively analysed and survival data were compared with existing studies in the literature.RESULTS: 1-, 2-, 3-, 4- and 5-year survival rates, when no stringent selection criteria were applied, were 92%, 65%, 51%, 41% and 29% respectively. To explore the impact of the number and size of CRLM on patients' survival, an exclusion of 13 patients(26.5%) with number of CRLM ≥ 5 and tumour size ≥ 40 mm resulted in 1-, 2-, 3-, 4- and 5-year survival rates improving to 94%, 69%, 53%, 42% and 31% respectively. It is of note that 9 of 49 patients developed extra-hepatic metastases, not visible or seen on pretreatment scans, just after RFA treatment. These patients had poorer survival. The development of extra-hepatic metastases in nearly 20% of the patients included in our study can partly account for modestly lower survival rates as compared with earlier studies in the literature.CONCLUSION: Our study underscores the fact that optimum patients' selection before embarking on RFA treatment is vitally important to achieving a superior outcome.     

Comparative study of resection and radiofrequency ablation in the treatment of solitary colorectal liver metastases

Background

We compared outcomes in patients with solitary colorectal liver metastases treated by either hepatic resection (HR) or radiofrequency ablation (RFA).

Methods

A retrospective analysis from a prospective database was performed on 67 consecutive patients with solitary colorectal liver metastases treated by either HR or RFA.

Results

Forty-two patients underwent HR and 25 patients underwent RFA. The 5-year overall and local recurrence-free survival rates after HR (50.1% and 89.7%, respectively) were higher than after RFA (25.5% and 69.7%, respectively) (P = .0263 and .028, respectively). In small tumors less than 3 cm (n = 38), the 5-year survival rates between HR and RFA were similar, including overall (56.1% vs 55.4%, P = .451) and local recurrence-free (95.7% vs 85.6%, P = .304) survival rates. On multivariate analysis, tumor size, metastases treatment, and primary node status were significant prognostic factors.

Conclusions

HR had better outcomes than RFA for recurrence and survival after treatment of solitary colorectal liver metastases. However, in tumors smaller than 3 cm, RFA can be recommended as an alternative treatment to patients who are not candidates for surgery because the liver metastases is poorly located anatomically, the functional hepatic reserve after a resection would be insufficient, the patient's comorbidity inhibits a major surgery, or extrahepatic metastases are present.     

对比微波消融与肝切除术治疗结直肠癌肝转移效果:Meta分析

目的采用Meta分析对比微波消融(MWA)与肝切除术(LR)治疗结直肠癌肝转移(CRCLM)的效果和安全性。方法检索PubMed、Embase、Cochrane Library、中国生物医学文献数据库、万方、中国知网、维普数据库关于MWA与LR治疗CRCLM的文献,检索时间自建库至2020年8月31日。依据纳入及排除标准筛选文献,以Review Manager 5.3和Stata 14软件进行Meta分析。结果最终纳入13篇文献、共1 534例CRCLM患者,MWA组685例,LR组849例。经异质性检验,1年总体生存率(OS)(I~2=0%,P=0.72)、3年OS(I~2=0%,P=0.86)、5年OS(I~2=0%,P=0.90)均无明显异质性,采用固定效应模型进行分析,结果显示MWA组与LR组间1年OS[HR=0.99,95%CI(0.95,1.02),P=0.44]、3年OS[HR=1.02,95%CI(0.93,1.11),P=0.74]差异均无统计学意义,LR组5年OS高于MWA组[HR=0.82,95%CI(0.69,0.97),P=0.02]。异质性检验示并发症无明显异质性(I~2=0%,P=0.78),以固定效应模型进行分析,结果显示MWA组并发症发生率低于LR组[RR=0.35,95%CI(0.23,0.52),P0.000 01)]。结论 MWA治疗CRCLM早、中期疗效(1、3年OS)与LR相当,远期疗效(5年OS)不及LR,但安全性更高。     

肝切除和微波消融治疗结直肠癌肝转移的效果比较

目的 比较肝切除和微波消融（microwave ablation,MWA）治疗结直肠癌肝转移（CRLM）的疗效。方法 回顾性分析2013年1月至2020年7月98例CRLM患者的临床资料,根据治疗方法不同分为2组,肝切除组31例,MWA组67例。MWA组共治疗105个病灶,其中特殊部位病灶36个,非特殊部位病灶69个。Kaplan-Meier法绘制生存曲线,Log-rank（Mantel-Cox）检验比较两组肿瘤复发率和生存差异。χ²检验比较两组消融不完全率,单因素和多因素Logistic回归分析消融不完全的危险因素。结果 随访截止2020年10月30日,中位随访时间38（4～94）个月。肝切除组中位肝内复发时间22（95%CI 13～49）个月,明显长于MWA组9（95%CI 6～12）个月（P＜0.001）。肝切除组中位生存时间为60（95%CI 33～86）个月,也明显长于MWA组36（95%CI 30～41）个月（P=0.040）。肝切除组和MWA组1、5年累积生存率无统计学差异（100% vs97%,χ² =0.945,P=1.000;36% vs 27%,χ²=0.437,P=0.508）。肝切除组3年累积生存率高于MWA组（74% vs 48%,χ² =6.013,P=0.014）。特殊部位组消融不完全率明显高于非特殊部位[33.3%（12/36）vs 15.9%（11/69）,χ² =4.183,P=0.041]。肿瘤直径≥3 cm、特殊部位、CEA≥200 ng/mL是消融不完全的危险因素,其中肿瘤直径≥3 cm是消融不完全的独立危险因素。结论 可切除性CRLM手术切除的疗效优于微波消融,直径大于3 cm的肿瘤不宜微波消融治疗。     

肝切除联合术中热消融治疗肝硬化背景下多灶性肝癌

目的探讨肝切除联合术中热消融治疗肝硬化背景下多灶性肝癌的有效性和安全性。方法回顾性分析63例接受肝切除联合术中热消融治疗肝硬化背景下多灶性肝癌患者的临床资料,分析患者的治疗效果及并发症。结果 63例患者共切除病灶85个,病灶平均最大直径(4.66±3.82)cm,热消融治疗病灶146个,病灶平均最大直径(1.48±0.66)cm。146个病灶完全消融率达100%(146/146),局部复发率4.11%(6/146)。患者1、2、3、4年无瘤生存率分别为54.82%、31.28%、12.03%、6.02%;1、3、5年累积生存率分别为83.51%、56.83%、45.20%。未出现治疗相关的死亡病例。肝切除相关严重并发症8例(8/63,12.70%)。未出现热消融相关严重并发症。结论肝切除联合术中热消融治疗肝硬化背景下多灶性肝癌安全、有效,扩大了肝切除术的适应证。     

经皮射频治疗结直肠癌肝转移31例

目的 评价B超引导经皮射频（PRFA）治疗结直肠癌肝转移的疗效。方法 应用PRFA治疗结直肠癌肝转移31例共55个病灶，肿瘤直径1．5～8．5cm。应用RF2000射频仪和10电极LeVeen针，病灶〉2．5cm者予分层多点叠合毁损，〉5．0cm或多发者配合肝动脉导管化疗栓塞术（TACE）及无水酒精注射疗法（PEI），随访观察病灶影像形态表现、血清CEA变化和患者生存率。结果 PRFA后反应期3～7d，包括局部疼痛不适、发热、ALT升高等；并发肝曲结肠穿孔和腹壁穿刺道转移各1例；小肿瘤（〈3．0cm）完全坏死率达92．9％（26／28），3．1～5．0cm的肿瘤完全坏死率为73．3％（11／15），病灶〉5cm者均未完全坏死；1、2、3年生存率分别为87．1％、77．5％和54．8％。结论 PRFA是治疗结直肠癌肝转移的一种微创疗法，对〈3．0cm肿瘤疗效显著，对大肿瘤可联合TACE、PEI等进行综合治疗。     

大肠癌肝转移射频消融后局部复发影响因素的分析

目的 探讨射频消融（radiofrequency ablation,RFA）治疗大肠癌肝转移后局部肿瘤复发的风险因素。方法 回顾性研究213例347个肿瘤实施RFA治疗后局部复发的临床资料,对可能影响RFA局部治疗效果的临床因素进行统计学处理。结果 175例（82.2%）298个肿瘤（85.9%）得到CT或MRI随访资料。大肠癌肝转移灶RFA后肿瘤局部复发率为36.9%（110/298）,局部复发的平均时间为16.4月（2～57个月）。单因素分析显示肝脏转移灶的部位、大小和射频针类型与肿瘤射频后的局部复发相关（P值分别为P=0.000,P=0.021和P=0.026）,但Cox多因素分析则显示只有瘤大小和转移灶部位是大肠癌肝转移射频消融后局部复发的独立预后因素（χ^2=8.522,P=0.000;χ^2=1.321,P=0.022）。结论 肝脏肿瘤的大小和部位是RFA治疗效果的独立影响因素,正确的电极选择和布针是获得肿瘤完全坏死的关键。     

肝切除术联合微波消融与单纯肝切除术治疗原发性肝癌疗效比较的临床研究

目的 探讨术中肝切除术联合微波消融和单纯肝切除术治疗原发性肝癌的疗效差异.方法 选取2005年1月-2013年12月武汉大学人民医院收治的原发性肝癌患者84例,按照手术方式不同分成联合组和单纯组,每组各42例.联合组患者采用术中肝切除术联合微波消融给予治疗,单纯组患者采用单纯肝切除术给予治疗.结果 联合组术中出血量为(323.9 ±93.1) ml,单纯组为(524.5±119.2) ml,P＜0.05.联合组术后肿瘤复发率为14.2％,单纯组为33.3％,P=0.040.联合组1年、3年、5年生存率均分别为96.5％、67％、51％,单纯组分别为84％、49.5％、36.5％,差异均有统计学意义(P =0.036).联合组手术时间为(177.7 ±30.7) min,单纯组为(165.1 ±29.5) min,P=0.058.联合组术后住院时间(15.5±3.7)d,单纯组为(14.0±4.0)d,P=0.068.联合组和单纯组术后第1天肝功能ALT、AST、ALB、TBIL变化,术后并发症发病率(包括胆瘘、发热、胸腔积液、大出血、腹腔感染及其他),差异均无统计学意义(P＞0.05).结论 术中肝切除术联合微波消融治疗原发性肝癌效果优于单纯肝切除术.     

Management of colorectal liver metastases

Hepatic metastases occur in 60% of patients following resection for colorectal cancer. Liver resection is the only curative option, with one third of resected patients alive at five years. In those developing recurrence in the liver following resection, further liver surgery may be curative, with similar 5 years survival rates of about 30%. Until recently surgery was feasible in only 15–25% of patients with colorectal liver metastases. New strategies, such as downstaging chemotherapy, portal vein embolization and two‐stage hepatectomy, may increase the resectability rate by 15%. Earlier detection of liver metastases would increase resectability, although good follow‐up trials are lacking. Once suspected, colorectal liver metastases are staged by spiral CT, CT portography and MRI, which have similar overall accuracies. Mortality following liver resection is less than 5% in major centres, with a morbidity rate of 20% to 50%. Prognostic scoring systems can be used to predict the likely cure rate with resection. Pulmonary metastases occur in 10–25% of patients with resected colorectal cancer, but are limited to the lung in only 2% of cases. In these selected cases surgery provides long‐term survival in 20–40%, and repeat lung resection has shown similar rates. For patients with unresectable disease, chemotherapy and ablation techniques have been demonstrated to prolong survival, although chemotherapy alone has been shown to improve quality of life.     

The management of solitary colorectal liver metastases

Surgical resection of solitary colorectal liver metastases is associated with long-term survival. Radiofrequency ablation used as the primary treatment option of solitary resectable colorectal liver metastases is associated with an increased risk of local recurrence that generally leads to worse survival compared to resection. In contrast with treatment of other hepatic malignancies, radiofrequency ablation is not equivalent to resection for colorectal liver metastases and should not be used as an alternative but limited to inoperable patients. Although overall survival rate after resection can be up to 71% at 5 years, the majority of patients develop recurrence. Preoperative chemotherapy contributes to decrease the risk of recurrence after resection of colorectal liver metastases. In patients with advanced solitary colorectal liver metastasis initially non suitable for resection, chemotherapy and portal vein embolization contribute to increase the number of surgical candidates whereas radiofrequency is rarely an option.     

Feasibility of adjuvant hepatic arterial infusion of chemotherapy after radiofrequency ablation with or without resection in patients with hepatic metastases from colorectal cancer

Background: The safety of combined hepatic artery infusion chemotherapy (HAI) and radiofrequency ablation (RFA) for liver metastases has not been assessed. We conducted a study to determine the feasibility of using HAI after RFA for colorectal cancer (CRC) liver metastases.Methods: Between 1996 and 2001, patients with hepatic metastases from CRC were enrolled onto a prospective study of RFA plus HAI consisting of continuous-infusion floxuridine and bolus fluorouracil. Surgical complications, treatment-related toxicities, and patient outcomes were recorded.Results: Fifty patients were treated with RFA and HAI with or without resection. A median of two lesions per patient, with a median greatest diameter of 2.0 cm, were treated with RFA. Postoperative complications, including 1 death, occurred in 11 of 50 patients. Toxicity from HAI was relatively mild. At 20 months median follow-up, 32% of patients remained disease free. Ten percent of patients had recurrences at the site of RFA, 30% developed new liver metastases, and 48% developed extrahepatic disease.Conclusions:RFA of CRC liver metastases followed by HAI is feasible and is associated with acceptable complication and toxicity rates. The high rate of disease recurrence in our patients indicates that novel combinations of regional and systemic therapies are needed to improve patient outcomes.     

Staged or simultaneous resection of synchronous liver metastases from colorectal cancer – a systematic review

Objective  A systematic review of the literature was undertaken to estimate the differences in length of hospital stay, morbidity, mortality and long-term survival between staged and simultaneous resection of synchronous liver metastases from colorectal cancer to determine the level of evidence for recommendations of a treatment strategy.
Method  A Pub-med search was undertaken for studies comparing patients with synchronous liver metastases, who either had a combined or staged resection of metastases. Twenty-six were considered and 16 were included based on Newcastle Ottawa Quality Assessment Scale. All studies were retrospective and had a general bias, because the staged procedure was significantly more often undertaken in patients with left-sided primary tumours and larger, more numerous and bi-lobar metastases. Analyses of primary outcomes were performed using the random effects model.
Results  For the reason of the heterogeneity of the observational studies, no odds ratios were calculated. In 11 studies, there was a tendency towards a shorter hospital stay in the synchronous resection group. Fourteen studies compared total perioperative morbidity and lower morbidity was observed in favour of a combined resection. Fifteen studies compared perioperative mortality, which seemed to be lower with the staged approach. Eleven studies compared 5-year survival, which seemed to be similar in the two groups.
Conclusion  No randomized controlled trials were identified, and hence a meta-analysis was not performed. The evidence level is II to III with grade C recommendations. Synchronous resections can be undertaken in selected patients, provided that surgeons specialized in colorectal and hepatobiliary surgery are available.     

超声引导下微波消融治疗肝转移癌38例

目的分析超声引导下微波消融治疗肝转移癌的临床疗效。方法回顾性分析肝转移癌患者超声引导下微波消融治疗38例患者共78个结节的局部疗效、并发症和远期生存率。结果消融术后肿瘤结节的完全消融率为93．6％（73／78）,局部复发率为6．8％（5／73）,未出现主要并发症。首次消融后患者的1、3、5年累计生存率分别为78．7％、53．6％、42．2％。结论微波消融是治疗肝转移癌安全、有效的手段。     

超声引导微波消融治疗肝脏转移性神经内分泌肿瘤

目的评估微波消融治疗肝脏转移性神经内分泌肿瘤的可行性、安全性及有效性。方法对6例（14个病灶）神经内分泌肿瘤肝脏转移患者行超声引导下微波消融治疗,观察肿瘤的大小变化、不良反应及并发症。结果技术有效率为92.86%（13/14）。术后1例患者出现发热,1例出现疼痛,1例病灶靠近膈肌者出现反应性胸腔积液,因疼痛诱发急性冠状动脉综合征。1例患者的1个病灶于治疗后3个月出现局部进展;另外13个病灶微波治疗后在增强影像中均未见强化,且随着随访时间延长而缩小。结论微波消融对肝脏神经内分泌肿瘤转移病灶是一种安全、有效的非手术治疗手段。     

同期肝切除治疗结直肠癌同时性肝转移

目的探讨结直肠癌同时性肝转移肝肠同期手术的疗效。方法回顾性分析1994年8月至2004年12月在我院行外科手术治疗的121例同时性结直肠癌肝转移患者的临床资料。结果在121例同时性结直肠癌肝转移患者中,99例行结直肠癌根治性切除术,剔除2例行原位肝移植患者后,同期肝切除组41例（A组）,对肝转移瘤行姑息外科治疗组56例（B组）,即转移瘤未能完全经手术切除者,A、B组患者性别、年龄、原发瘤部位、浸润深度、淋巴结转移等差异均无统计学意义,肝转移瘤数目（x^2=40.41,P＜0.05）、肝转移瘤分布（x^2=11.61,P＜0.05）差异有统计学意义;两组患者中位生存期分别为28.9个月、17.1个月,5年生存率分别为14％、0,其中A组患者中位无瘤生存期为19.5个月,1、3、5年生存率为93%、44%和14%。结论同期肝切除能为部分结直肠癌同时性肝转移患者提供治愈机会,对于合适的患者应力争行同期肝切除术。     

射频消融联合经皮椎体后凸成形术治疗脊柱转移癌的临床初步研究

目的 初步探讨射频消融(radiofrequency ablation,RFA)联合经皮椎体后凸成形术(percu-taneous kyphoplasty,PKP)治疗脊柱转移癌的临床疗效.方法 对2013年9月至2015年9月于广元市中心医院骨科行RFA联合PKP治疗脊柱转移癌的18例(24椎)病人的临床资料进行回顾性分析,比较其术前、术后1 d、1周及1、2、3、6个月的疼痛视觉模拟量表(visual analogue scales,VAS)评分、日本骨科协会(Japanese Orthopaedic Association,JOA)评估治疗分数、罗兰-莫里斯生活障碍问卷(Rolando-Morris dis-ability questionnaire,RMDQ)评分,同时通过术后随访复查的X线片,测量椎体前缘高度,记录骨水泥渗漏情况.结果 全部病人术后24 h内疼痛明显缓解,技术成功率为100%,均得到3个月以上随访,平均随访时间为5.2个月.术后3个月,9例(50.0%)疼痛完全缓解,7例(38.9%)止痛药用量减少或止痛药级别降低,2例(11.1%)止痛药维持原量.治疗后(术后1 d、1周及1、2、3、6个月)的VAS、JOA、RMDQ评分及椎体前缘高度均较治疗前显著改善,差异均有统计学意义(P均<0.05).结论 RFA联合PKP可明显提高病人生活质量,手术方式安全,对脊柱转移癌病人微创、有效.     

Long-term outcomes after hepatic resection combined with radiofrequency ablation for initially unresectable multiple and bilobar liver malignancies

Background

Hepatic resection (HRE) combined with radiofrequency ablation (RFA) offers a surgical option to a group of patients with multiple and bilobar liver malignancies who are traditionally unresectable for inadequate functional hepatic reserve. The aims of the present study were to assess the perioperative outcomes, recurrence, and long-term survival rates for patients treated with HRE plus RFA in the management of primary hepatocellular carcinoma (HCC) and metastatic liver cancer (MLC).

Methods

Data from all consecutive patients with primary and secondary hepatic malignancies who were treated with HRE combined with RFA between 2007 and 2013 were prospectively collected and retrospectively reviewed.

Results

A total of 112 patients, with 368 hepatic tumors underwent HRE combined with ultrasound-guided RFA, were included in the present study. There were 40 cases of HCC with 117 tumors and 72 cases of MLC with 251 metastases. Most cases of liver metastases originated from the gastrointestinal tract (44, 61.1%). Other uncommon lesions included breast cancer (5, 6.9%), pancreatic cancer (3, 4.2%), lung cancer (4, 5.6%), cholangiocarcinoma (4, 5.6%), and so on. The ablation success rates were 93.3% for HCC and 96.7% for MLC. The 1-, 2-, 3-, 4-, and 5-y overall recurrence rates were 52.5%, 59.5%, 72.3%, 75%, and 80% for the HCC group and 44.4%, 52.7%, 56.1%, 69.4%, and 77.8% for the MLC group, respectively. The 1-, 2-, 3-, 4-, and 5-y overall survival rates for the HCC patients were 67.5%, 50%, 32.5%, 22.5%, and 12.5% and for the MLC patients were 66.5%, 55.5%, 50%, 30.5%, and 19.4%, respectively. The corresponding recurrence-free survival rates for the HCC patients were 52.5%, 35%, 22.5%, 15%, and 10% and for the MLC patients were 58.3%, 41.6%, 23.6%, 16.9%, and 12.5%, respectively.

Conclusions

HRE combined with RFA provides an effective treatment approach for patients with primary and secondary liver malignancies who are initially unsuitable for radical resection, with high local tumor control rates and promising survival data.     

经皮热消融治疗可再手术切除的复发性肝细胞癌

目的评估经皮热消融治疗可再手术切除复发性肝细胞癌(RHCC)的临床疗效。方法 37例肝切除后 RHCC,肿瘤直径1.2～7.0 cm,平均(2.8±1.3)cm,临床评估可再切除但由于病人不愿意接受手术,采用超声引导经皮微波消融(MWA)或射频消融(RFA)治疗,观察局部疗效、治疗并发症和远期生存情况。结果肿瘤完全消融率(完全灭活率)91.9%(34/37),其中直径≤3 cm结节为95.8%、3 cm 以上者84.6%。并发症发生率5.4%(2/37),无治疗死亡。平均随访(20.5±14.4)个月,肿瘤局部复发与肝内远处复发率分别为21.2%、72.2%。消融后1、3年无瘤生存率分别为35.9%、17.4%,中位无瘤生存期为6.7个月;消融后1、3及5年累积生存率分别为70.0%、35.3%和35.3%,中位生存期为32.6个月;初次肝切除后1、3、5及10年生存率分别为85.1%、63.4%、41.0%和37.6%,中位生存期47.0个月。结论经皮热消融技术是可再手术切除 RHCC 的有效治疗手段。