原发性肝癌的治疗决策

原发性肝癌的病因主要是乙肝病毒及丙肝病毒,绝大多数肝癌患者合并有肝硬化.治疗手段的选择取决于肿瘤位置,转移及肝脏储备功能等因素.在合适的患者中,原发性肝癌首选治疗为肝切除术或肝移植.对不可手术的肝癌,则可选择局部消融治疗或肝动脉栓塞化疗.更晚期的患者只能作对症治疗.治疗选择的标准需以临床实验研究为基础.     

原发性肝癌的外科治疗进展

原发性肝癌是我国高发的恶性肿瘤之一，近年来其发病率有增高趋势，统计表明我国肝癌的年死亡率为２０４０／１０万，其中城市为１９９８／１０万，农村为２３５９／１０万，分别占恶性肿瘤死亡率的第二和第一位．全世界每年新发病的肝癌约４５％在我国大陆，尤以东...     

原发性肝癌外科治疗方法的选择

早在 2 0世纪 5 0年代中期 ,我国就已开展了外科手术治疗原发性肝癌的工作。近半个世纪以来 ,经过几代人的共同努力 ,原发性肝癌的外科治疗有了很大发展 ,取得了较好效果。当今的肝脏外科 ,已不存在手术禁区 ,也不认为巨大肝癌不能切除。目前 ,全世界比较一致的意见是 ,外科手术切除仍是治疗本病的首选方法和最有效的措施。与此同时 ,由于现代科学技术的高速发展 ,一些新的治疗技术相继出现 ,不断在临床上推广应用 ,并取得了一定的效果。这些技术包括 :放射介入治疗技术、射频治疗技术、Ｘ刀治疗技术、冷冻治疗技术、微波治疗技术 ,无水乙醇…     

原发性肝癌合并门静脉癌栓的外科治疗

肝癌是常见恶性肿瘤之一，其发病率和病死率居我国恶性肿瘤第二位。门静脉侵犯是肝癌重要的生物学特性。肝癌倾向于侵袭门静脉，并继而形成癌栓。临床报道肝癌门静脉癌栓（PVTT）发生率为44．0％～62．2％。肝癌侵袭门静脉是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，门静脉高压加剧，继而引发食道胃底静脉破裂出血，甚至导致肝功能衰竭。因此，肝癌合并PVTT患者总体预后差，中位生存时间仅2．7个月。     

肝移植治疗原发性肝癌

目的评价原位肝移植治疗原发性肝癌的疗效和受体选择,探讨原位肝移植在原发性肝癌治疗中的作用和地位.方法回顾性分析1999年1月至2005年2月完成的9 2例原发性肝癌肝移植患者的临床资料.结果原发性肝癌肝移植92例,根据国际抗癌协会的国际癌症病期分类（TNM）,Ⅰ期8例,ChildPugh均为A级;Ⅱ期13例,Child-Pugh A级11例、B级2例;Ⅲ期12例,Child-Pugh A级8例、B级3例、C级1例;Ⅳ期59例,Child-Pugh A级52例、B级5例、C级2例.手术成功75例,成功率81.5%,围手术期死亡17例,病死率18.5%.随访6～68个月,最短生存40 d,最长无瘤生存68个月,肿瘤最短51 d复发,生存时间3年以上的7例患者至今仍无瘤生存.Ⅰ期：1年生存者5例,2年生存者3例,3年生存者2例,5年生存者1例;Ⅱ期：1年生存者6例,2年生存者2例,3年生存者2例;Ⅲ期：1年生存者3例,无生存超过2年者;Ⅳ期：1年生存者18例,2年生存者5例,3年生存者3例,5年生存者1例.Ⅰ、Ⅱ期的生存率显著高于Ⅲ、Ⅳ期.术后出现原发性肝癌复发35例,总复发率为46.7%.Ⅰ、Ⅱ、Ⅲ、Ⅳ期的复发率分别为12.5%、0、50.0%和47.5%,Ⅲ、Ⅳ期的复发率明显高于Ⅰ、Ⅱ期.结论不同期原发性肝癌肝移植术后的生存情况差别较大,肝移植治疗早期原发性肝癌效果显著,进展期原发性肝癌由于移植效果差应持慎重态度.     

肝移植研究进展——肝移植治疗原发性肝癌

原发性肝癌曾是肝移植的主要适应证。肝移植的先驱Starzl和 Calne最初施行的 10例手术中 ,8例为肝脏恶性病变。但在肝移植用于肝癌治疗的最初实践中 ,结果令人失望 ,根据当时美国器官共享网络 (U NOS)的数据 ,其 5年生存率低于 30 %～ 4 0 %。因而许多学者对肝移植治疗肝癌的价值产生怀疑 ,以至于在一段时间内对其持消极甚至否定态度 ,导致肝癌被视为肝移植治疗的相对禁忌证。反对肝癌行肝移植治疗的主要理由包括 :1移植后免疫抑制状态下的肿瘤复发率高 ,长期生存率低。 2在供肝来源较紧张的情况下 ,仍将有限的供肝移植给疗效不确定的肝…     

原发性肝癌治疗方法的评价——肝切除术治疗原发性肝癌

在我国，肝切除术治疗原发性肝癌已有近50年的历史。尤其随着手术技术的不断改进，手术切除肝癌的疗效也在不断提高。近些年来，在原发性肝癌的治疗中，逐步开始采用经肝动脉置管栓塞化疗(TACE)、射频消融术和生物治疗等综合措施。但上述疗法均不能完全替代肝切除术。尤其随着手术技术的不断改进，手术切除肝癌的疗效也在不断提高。     

薏苡仁注射液治疗原发性肝癌的研究

目的：探讨薏苡仁注射液治疗原发性肝癌临床疗效。方法：对38例患者静脉注射薏苡仁注射液100ml/d,20d为1疗程,并与20例栓塞加化疗的患者进行对照,统计其对临床症状,肿块及生活质量的影响。结果：薏苡仁组在改善临床症状,提高生活质量方面明显优于对照组（P＜0．01）,但对肿块的缓解则两组无显著性差异。结论：薏苡仁注射液是一种疗效显著、安全的抗肿瘤药。     

重视原发性肝癌治疗的规范化

原发性肝癌患者病情复杂,宜根据病变的具体情况和各种治疗方法的不同特点和适应证选择最佳个体化方案.原发性肝癌的规范化治疗涉及诸多学科,需要多学科共同探讨,为患者选择最合适的首选治疗及综合治疗方案,对提高肝癌的总体疗效和改善患者的预后具有重要意义.为此,中国抗癌协会肝癌专业委员会(CSLC)和临床肿瘤学协作专业委员会(CSCO)以及中华医学会肝病学分会肝癌学组联合进行了深入研讨,形成了基本共识,对推动我国肝癌的规范化治疗作出了贡献.     

射频治疗原发性肝癌

射频消融是治疗原发性肝癌的新方法,其治疗小肝癌的价值已得到公认。近年其设备及治疗方法均有长足进步。多数学者主张,射频消融与其他疗法,如经导管动脉化学灌注栓塞治疗、氩氦刀冷冻消融、瘤内注射无水乙醇等联合,可用于治疗大肝癌。     

肝移植治疗原发性肝癌89例生存率分析

目的探讨肝移植治疗原发性肝癌（primary hepatic carcinoma,PHC）的术后生存率及其影响因素。方法回顾性分析2000年8月以来我院89例接受肝移植且随访时间≥6个月的PHC患者的临床资料。结果89例患者肝移植术后1、2和3年生存率分别为91．2％、68．5％、59．4％;单因素分析显示,肿瘤最大直径、门静脉癌栓、肿瘤分化程度和肿瘤TNM分期是影响生存率的重要因素,Cox风险模型多因素分析显示,肿瘤最大直径、肿瘤分化程度和肿瘤TNM分期是影响生存率的独立危险因素。结论肝移植是目前治疗PHC的有效方法,肿瘤直径〉5cm、肿瘤分化程度差和肿瘤TNM分期高均严重影响患者的生存率。     

提高原发性肝癌肝切除手术安全性的临床研究

目的探讨提高原发性肝癌（pfimau hepatic carcinoma,PHC）肝切除手术安全性的有效途径。方法回顾性分析403例PHC患者的临床资料,其中250例采用解剖性分离方法（A组）进行肝切除;153例采用传统钳夹法（B组）进行肝切除。比较2组术中出血及输血情况、术后肝功能、并发症发生率、手术死亡率及住院时间。结果A组肿瘤直径为（7．13±4．57）am,术中出血量为（438±225）ml,输血44例（17．6％）,输血量为（510±290）ml,无手术死亡及腹腔出血、肝衰竭等严重并发症,轻度并发症14例（5．6％）,术后住院时间为（11．3±5．1）d。B组肿瘤直径为（5．97±3．23）cm,术中出血量为（1200±360）ml,输血51例（33．3％）,输血量为（1440±663）ml,发生并发症42例（27．5％）,其中术后腹腔出血7例、肝衰竭6例,手术后30d内死亡7例（4．58％）,术后住院时间为（19．1±9．7）d。A组术中出血量、输血量、手术死亡率、术后严重并发症发生率、总并发症发生率、术后住院时间均低于B组（P〈0．05）。结论在积极的围手术期处理同时,采用解剖性分离法进行肝切除,可以显著提高PHC肝切除手术安全性。     

Progress in surgical and nonsurgical approaches for hepatocellular carcinoma treatment

BACKGROUND: Hepatocellular carcinoma (HCC) is a com-plex and heterogeneous malignancy, frequently occurs in the setting of a chronically diseased organ, with multiple con-founding factors making its management challenging. HCC represents one of the leading causes of cancer-related mortal-ity globally with a rising trend of incidence in some of the de-veloped countries, which indicates the need for better surgical and nonsurgical management strategies.
DATA SOURCES: PubMed database was searched for relevant articles in English on the issue of HCC management.
RESULTS: Surgical resection represents a potentially cura-tive option for appropriate candidates with tumors detected at earlier stages and with well-preserved liver function. The long-term outcome of surgery is impaired by a high rate of recurrence. Surgical approaches are being challenged by local ablative therapies such as radiofrequency ablation and micro-wave ablation in selected patients. Liver transplantation offers potential cure for HCC and also correction of underlying liver disease, and minimizes the risk of recurrence, but is reserved for patients within a set of criteria proposed for a prudent allocation in the shortage of donor organs. Transcatheter locoregional therapies have become the palliative standard allowing local control for intermediate stage patients with noninvasive multinodular or large HCC who are beyond the potentially curative options. The signiifcant survival beneift with the multikinase inhibitor sorafenib for advanced HCC has shifted the direction of research regarding systemic treat-ment toward molecular therapies targeting the disregulated pathways of hepatocarcinogenesis. Potential beneift is sug-gested from simultaneous or sequential multimodal therapies, and optimal combinations are being investigated. Despite the striking progress in preclinical studies of HCC immuno-therapy and gene therapy, extensive clinical trials are required to achieve successful clinical applications of these innovative approaches.
CONCLUSION: Treatment decisions have become increasing-ly complex for HCC with the availability of multiple surgical and nonsurgical therapeutic options and require a compre-hensive, multidisciplinary approach.     

Feasibility and validity of hepatic vein reconstruction in hepatectomy for hepatocellular carcinoma

The majority of hepatocellular carcinomas are complicated by liver cirrhosis. Cirrhotic patients with a tumor located in segments 7 and 8 cannot tolerate right lobectomy. To perform curative resection without causing liver failure in such patients, resection of segments 7 and 8, together with resection of the right hepatic vein, is recommended. Nine patients underwent such resection. In four patients, the right hepatic vein was not reconstructed. One patient died of liver failure and the other two patients had postoperative liver dysfunction. Based on this experience, the right hepatic vein was reconstructed in the remaining five patients; the defect was repaired by transplanting a vein graft in three patients, and a patch graft was carried out in two. In one patient who underwent reconstruction with vein graft, veno-venous bypass was performed between the remnant hepatic vein and inferior vena cava. This procedure decompressed the remnant liver and facilitated secure anastomosis in reconstruction of the hepatic vein. There were no complications or deaths. The reconstructed veins were patent 2–3 years postoperatively. This procedure is feasible and valid, and should be widely practiced in patients with a diminished liver function reserve.     

Assessment of safety in hepatic resection for hepatocellular carcinoma focusing on indirect hyperbilirubinemia

Background/purpose

The indications for hepatic resection for hepatocellular carcinoma (HCC) patients with total bilirubin (T-Bil) equal to or higher than 1.2 mg/dl remain controversial. The aim of this study was to investigate the safety of hepatic resection for HCC patients who showed high T-Bil (≥1.2 mg/dl) with low direct bilirubin (D-Bil ≤ 0.5 mg/dl).

Methods

Thirty-four HCC patients showing high T-Bil with low D-Bil were treated with mono- to tri-segmentectomy between January 2000 and December 2010. The perioperative clinical parameters and prognosis of the high T-Bil/low D-Bil patients were compared with those of 253 HCC patients showing normal T-Bil. In addition, complication rates of the patients with high T-Bil/high D-Bil (n = 4) were analyzed.

Results

The prothrombin time activity, indocyanine green clearance test, asialo-scintigraphy, and platelet count were similar in the two groups. The mean serum albumin in high T-Bil/low D-Bil patients was significantly higher than that of normal T-Bil patients (4.2 ± 0.5 vs. 4.0 ± 0.4 g/dl, P = 0.004). There were no significant differences in operation time, intraoperative bleeding, red cell concentrate transfusion rate, postoperative complication rate, and disease-free and overall survivals between the two groups. Postoperative hyperbilirubinemia (T-Bil >5 mg/dl) with ascites was observed in one of four high T-Bil/high D-Bil patients (25 %).

Conclusions

Mono- to tri-segmentectomy can be performed in patients with low D-Bil (≤0.5 mg/dl) similarly to patients with low T-Bil (<1.2 mg/dl), even in HCC patients showing high T-Bil (≥1.2 mg/dl).     

Successful surgical treatment for implanted intraperitoneal metastases of hepatocellular carcinoma

We report here two patients with hepatocellular carcinoma who experienced implanted metastases in the abdominal cavity after hepatectomy or microwave coagulo-necrotic therapy. Hepatic resection and microwave coagulo-necrotic therapy were successful for these tumors, and the postoperative status was satisfactory in both patients. Implanted metastases were discovered in the abdominal cavity of each of these two patients 6 months after surgery. It is necessary to look not only for the presence of liver metastasis but also for the recurrence of the tumor in the abdominal cavity during the follow-up period. Generally, surgical resection for intraabdominal implanted tumors arising from any other abdominal organs is not indicated for improving the patient's quality of life. However, resection of metastatic tumors that occur in the abdominal cavity, arising from hepatocellular carcinoma may be of value in improving patient survival.