原发性大肝癌调强放疗的疗效及预后分析

目的探讨调强放射治疗对不适宜手术以及射频消融、介入等其他局部治疗无效的原发性大肝癌的临床疗效及预后影响因素。方法回顾性分析2008年4月-2011年8月武警总医院肿瘤内科收治的29例接受调强放疗的原发性大肝癌患者的临床资料。单次剂量2~6 Gy,5 F/w,总剂量50~70 Gy。观察近期疗效及预后。生存率计算采用Kaplan-Meier法,差异性检验采用Log-rank法,并采用Cox回归模型进行多因素分析。结果完全缓解率3.57%,部分缓解率32.14%,疾病稳定率53.57%,进展率10.72%,总体中位无进展生存时间(PFS)6.43个月,中位生存期(OS)11.43个月,1、2年生存率分别为46.79%和25.23%。单因素分析显示肿瘤缓解率为PFS的独立预后因子,Cox多因素分析显示PFS的独立预后因子为肿瘤缓解率和处方剂量,OS的独立预后因素为肿瘤缓解率、肿瘤直径、肿瘤体积。常见放疗急性不良反应为胃肠道不适、放射性肝损伤及骨髓抑制。结论调强放疗对于不能手术治疗及其他局部治疗无效的原发性大肝癌是一个安全、有效的选择。     

原发性肝癌合并门静脉癌栓免疫治疗进展

据报道[1] ,2018年全球原发性肝癌(primary liver cancer , PLC )新增病例约84 .1万例,发病率位居第六位;死亡约78 .2万例,死亡率位居第四位.我国数据显示,PLC发病率及死亡率分别位居第四位和第二位[2 ].其中,有44 .0％ ～62 .2％ 的PLC合并门静脉癌栓(porta...     

三维适形放疗与调强放疗治疗原发性肝癌伴门静脉癌栓的剂量学比较

目的评估三维适形放疗(3DCRT)与调强放疗(IMRT)2种不同放疗技术在原发性肝癌伴门静脉癌栓放射治疗中的优缺点。方法 20例不能手术的原发性肝癌并门静脉癌栓的患者分别进行3DCRT和IMRT 2种放疗计划设计,处方剂量均为40 Gy/20 f。比较2组计划的靶区与危及器官剂量学参数及加速器跳数(MU)。2组间比较采用t检验。结果 IMRT在计划靶体积(PTV)的剂量覆盖、均一性及适形度均优于3DCRT(P0.05);3DCRT与IMRT的肝V30 Gy及肝V20 Gy分别为33.55±5.67vs 29.41±2.67(P=0.001)和44.24±6.17 vs 41.28±4.59(P=0.021)。2组的正常肝组织低剂量区范围与胃、小肠、脊髓、双肾的受照射剂量并无显著性差异。3DCRT与IMRT的MU分别为303.7±35.8和377.4±33.2(P=0.000)。结论与3DCRT相比,IMRT有较满意的PTV高剂量覆盖及均匀的剂量分布。在危及器官保护方面,IMRT的肝脏高剂量区范围明显低于3DCRT,而不足的是,IMRT的治疗时间显著长于3DCRT。     

原发性肝癌合并门静脉癌栓的影像学特征

原发性肝癌(PHC)对血管系统的浸润发生率很高,特别是门静脉癌栓(PCT)多见。我们对门静脉癌栓患者的B超实时显像(BUS)、数字减影血管造影(DSA)、电子计算机断层(CT)进行了对比研究,现总结分析如下。 一、资料与方法 本组原发性肝癌合并门静脉癌栓100例.男 8 2例,女 18例,平均年龄5 4岁,均经临床     

原发性肝癌合并门静脉癌栓的外科治疗

目的:探讨原发性肝癌合并门静脉癌栓的外科治疗及提高疗效的方法。方法:采用肝叶切除和经门静脉残端或主干切开取癌栓术治疗32例PHC合并PVTT患者,12例术后联合门静脉、肝动脉介入化疗,5例合并门静脉高压联合行断流术、脾切除或脾动脉结扎术。总结其临床资料、治疗方法、术后并发症及疗效预后,并进行统计学分析。结果:①本组病例术中出血量、输血量、肝门阻断次数时间、术后并发症发生率与同期50例单纯肝癌切除组比较无显著性差异(P>0.05)。②术后并发症:9例肝功能不全,3例术后肝断面出血、5例右胸腔积液、2例上消化道出血,1例术后3个月死于肝功能衰竭,其余恢复良好。③疗效与预后:随访26例,1、2、3年生存率分别为50％、34.6％、15.4％;术后化疗、术前肝功能状况对预后有显著影响。结论:肝叶切除和经门静脉残端或主干切开取癌栓是治疗原发性肝癌合并门静脉癌栓最有效的方法,改善术前肝功能及术后联合化疗,对提高生存期意义重大;门静脉取癌栓联合贲门周围血管断流、和/或脾切除、脾动脉结扎术能有效治疗肝癌合并门静脉高压,减少上消化道出血并发症;对于难以切除的PHC合并PVTT应争取行TACE术,仍有二期手术切除的机会。     

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。     

原发性肝癌伴门静脉癌栓临床分析

原发性肝癌 (ＰＨＣ)伴门静脉癌栓 (ＰＶＴＴ)临床分期为Ⅲ期[1] ,预后差。近几年由于肝癌的诊治进展 ,临床生存期得到延长 ,探索ＰＶＴＴ的临床和病理特点及其诊治方法倍受关注。本文对ＰＨＣ伴ＰＶＴＴ 35例进行临床分析。1　资料与方法1.1　临床资料　收集 1996年 1月至 2 0 0 0年 11月我院住院的临床资料完整的ＰＨＣ 110例。全部病例符合 1999年第四届全国肝癌学术会议修订诊断标准[1] 。其中并发ＰＶＴＴ 35例 (占 31 8% ) ,男 31例 ,女 4例 ,年龄 31～ 73岁 ,平均 4 8.8岁。ＰＶＴＴ部位 :门静脉左支癌栓 7例 ,右支癌栓 5例 ,左右支…     

肝癌合并门静脉癌栓的介入治疗

针对肝癌合并门静脉癌栓(PVTT)的介入治疗方法,包括化疗栓塞、消融术、放疗、栓塞放疗等。近年来,更多的倾向于根据患者的具体情况,实施个体化的综合治疗。1.肝动脉化疗栓塞术(TACE) TACE是成熟的、有效的治疗肝癌的方法之一。既往对于肝癌合并PVTT,尤其是门静脉主干癌栓者,因恐诱发肝功能衰竭,TACE被视为禁忌。近年来,有学者认为,PVTT多数     

TACE治疗不可切除原发性肝癌合并下腔静脉癌栓1例

原发性肝癌(primary liver cancer,PLC)直接侵犯下腔静脉形成癌栓较少见,预后极差。有研究表明,对于原发病灶可切除的患者,外科切除联合取栓术是可行的治疗选择;而针对原发病灶不可切除的患者,目前尚无具体治疗建议。现报道1例不可切除PLC合并下腔静脉癌栓患者行肝动脉栓塞化疗(transcatheter arterial chemoembolization,TACE)治疗的经过。     

立体定向放射治疗原发性肝癌伴下腔静脉癌栓的疗效评价

目的评价立体定向放疗治疗肝细胞癌伴下腔静脉癌栓的疗效。方法在66例肝细胞癌伴下腔静脉癌栓患者中,36例接受立体定向放射治疗,30例未接受放射治疗。结果 36例接受伽玛刀治疗的癌栓患者,12例（33.3%）癌栓完全缓解,10例（27.8%）部分缓解,13例（36.1%）稳定,1例（2.8%）进展。癌栓治疗有效率为61.1%,1年生存率为27.8%,中位生存期为9.8个月;未放疗的30例患者1年生存率为11.5%,中位生存期为3.5个月。多因素分析显示,放疗组病人生存情况与肝内病灶单多发有关。Child-Pugh分级是影响预后的主要因素。结论立体定向放射治疗可明显延长肝细胞癌伴有下腔静脉癌栓患者的生存期。     

The effectiveness of particle radiotherapy for hepatocellular carcinoma associated with inferior vena cava tumor thrombus

Background

The prognosis of patients who have hepatocellular carcinoma (HCC) associated with inferior vena cava tumor thrombus (IVCTT) is very poor, and effective treatment modalities are extremely limited. The objective of this study was to determine the therapeutic efficacy of particle radiotherapy for HCC with IVCTT.

Methods

Between June 2001 and January 2009, 16 evaluable patients who had HCC with IVCTT were treated with particle radiotherapy. They were divided into 2 groups: 6 were treated with curative intent; 10 with palliative intent. The local tumor control rates, overall survival rates, and toxicities were evaluated.

Results

All tumors treated with particle radiotherapy remained controlled without local recurrence at the last follow-up. The overall survival rates for the 16 patients at 1 and 3?years were 61.1 and 36.7%, respectively. We observed a significant difference in the survival rates according to treatment policy. The median survival time was 25.4?months for patients treated with curative intent and 7.7?months for those treated with palliative intent. The one-year survival rates were 100.0 and 33.3%, respectively. No Grade 3 or higher treatment-related toxicities were observed.

Conclusions

Particle radiotherapy is thought to be potentially effective and safe for HCC with IVCTT. Considering the current lack of effective and less-invasive local therapy for HCC with IVCTT, particle radiotherapy may therefore be an attractive new therapeutic approach for this type of HCC.     

Hepatectomy for hepatocellular carcinoma with portal vein tumor thrombus

Despite surgical removal of tumors with portal vein tumor thrombus(PVTT) in hepatocellular carcinoma(HCC) patients, early recurrence tends to occur, and overall survival(OS) periods remain extremely short. The role that hepatectomy may play in long-term survival for HCC with PVTT has not been established. The operative mortality of hepatectomy for HCC with PVTT has also not been reviewed. Hence, we reviewed recent literature to assess these parameters. The OS of patients who received hepatectomy in conjunction with multidisciplinary treatment tended to be superior to that of patients who did not. Multidisciplinary treatments included the following: preoperative radiotherapy on PVTT; preoperative transarterial chemoembolization(TACE); subcutaneous administration of interferon-alpha(IFN-α) and intra-arterial infusion of 5-fluorouracil(5-FU) with infusion chemotherapy in the affected hepatic artery; cisplatin, doxorubicin and 5-FU locally administered in the portal vein; and subcutaneous injection of IFN-α, adjuvant chemotherapy(5-FU + Adriamycin) administration via the portal vein with postoperative TACE, percutaneous isolated hepatic perfusion and hepatic artery infusion and/or portal vein chemotherapy. The highest reported rate of operative mortality was 9.3%. In conclusion, hepatectomy for patients affected by HCC with PVTT is safe, has low mortality and might prolong survival in conjunction with multidisciplinary treatment.     

Surgical treatment for hepatocellular carcinoma with portal vein tumor thrombus

BACKGROUND/AIMS: To study the value of surgical treatment for hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT). METHODOLOGY: From January 1997 to December 2001, 63 cases of HCC with portal vein tumor thrombus underwent liver resection combined with PVTT removal (group 1). Between December 2001 and December 2003, 20 patients received adjuvant portal vein chemotherapy (PVC) after the surgical procedures mentioned above (group 2). Treatment outcome and the surgical features in these two groups were studied. RESULTS: The median overall survival in group 2 was significantly longer than that in group 1 (10.9 months vs. 7.8 months, p < 0.05). There were significant differences between the survival of the two groups (log-rank, p < 0.05). In group 1 the 1-, 3-, and 5-year survival rates were 18.0%, 14.8% and 1.6%, respectively. In group 2 the 1-year survival rate was 30%. CONCLUSIONS: Liver resection combined with PVTT removal and the postoperative PVC is beneficial to the survival of HCC patients with PVTT. Postoperative PVC might enhance the effect of these surgical approaches.     

Successful management of the hepatocellular carcinoma with inferior vena cava tumor thrombus: A case report

Rationale:Hepatocellular carcinoma (HCC) with inferior vena cava tumor thrombus (IVCTT) is traditionally considered an advanced-stage cancer with a poor prognosis. There is no standard treatment for patients diagnosed as HCC with IVCTT.Patient concerns:A 52-year-old man was admitted to our hospital because of suspected hepatic mass during a health examination.Diagnoses:Computed tomography (CT) showed a hepatic mass approximately 4.3 cm × 6.3 cm in size located in segment VII of the liver, with thrombus in the inferior vena cava. The mass exhibited a pattern of early enhancement and washout on contrast-enhanced CT. Alpha-fetoprotein was 614.1 ng/mL (normal value, <8 ng/mL). The preoperative diagnosis was HCC with IVCTT.Interventions:Two months after stereotactic body radiotherapy combined with sorafenib therapy, a planned open anatomical resection of the right posterior lobe of the liver was performed.Outcomes:The patient is alive without disease 12 months after surgery, and the level of alpha-fetoprotein is normal.Lessons:The patient diagnosed as HCC with IVCTT was successfully treated by stereotactic body radiotherapy combined with molecularly targeted drugs followed by surgical treatment. If confirmed in future studies, this would suggest a promising strategy for the management of HCC with IVCTT.     

Aggressive surgical resection for hepatocellular carcinoma with tumor thrombus extending to inferior vena cava and synchronous pulmonary metastasis

We describe a 66-year-old man having hepatocellular carcinoma with tumor thrombus extending into the inferior vena cava and synchronous pulmonary metastasis. He was referred to Chiba University Hospital on May, 2000, complaining of emaciation. Radiological findings showed a huge hepatocellular carcinoma in the entire right lobe and tumor thrombus extended into the intrapericardial inferior vena cava. He also had a solitary pulmonary metastasis in the left pulmonary lobe (stage IVB). Right hemihepatomy was performed under total hepatic vascular exclusion without cardiopulmonary bypass, and tumor thrombus was completely removed. Thoracoscopic wedge resection of pulmonary metastasis was also performed. The patient had an uneventful postoperative course. Histopathological examination revealed that the tumor was moderately differentiated hepatocellular carcinoma The patient is still alive after 26 months with pulmonary recurrence, but without hepatic recurrence. To our knowledge, there has been no reported case of resection for both hepatocellular carcinoma invading the inferior vena cava and synchronous pulmonary metastasis. In conclusion, aggressive surgical resection for advanced hepatocellular carcinoma concomitant with pulmonary resection may bring about better prognosis in highly selected patients.     

Surgical treatment for advanced hepatocellular carcinoma with portal vein tumor thrombus

The Barcelona Clinic Liver Cancer staging system recommends a tyrosine kinase inhibitor (sorafenib) as standard therapy in advanced hepatocellular carcinoma (HCC) patients with portal vein tumor thrombus (PVTT). Sorafenib has been shown to prolong median overall survival (OS) by approximately 3 months in advanced HCC patients with PVTT (8.1 vs. 4.9 months). However, its clinical effectiveness is still controversial and standard treatment with sorafenib is not established in Japan. Surgical resection is considered a potentially curative treatment and provides an acceptable outcome for carefully selected patients. The surgical mortality rate in patients with PVTT who receive surgical resection ranges from 0% to 10%. The median survival time and 1-year OS rate in HCC patients with PVTT who undergo surgical resection have been found to range from 8 to 22 months and 21.7% to 69.6%, respectively. But improvement in therapeutic outcome is difficult with surgical treatment alone. Combination treatment in conjunction with such methods as transarterial chemoembolization, hepatic artery infusion chemotherapy, and radiotherapy has been found to improve the prognosis (median survival time, 11.5–37 months; 1-year OS rate, 46.8–100%). Yet, many problems remain, such as surgical indications and surgical techniques. After resolving these points, a multidisciplinary strategy based on surgical treatment should be established for advanced HCC with PVTT.     

肝细胞癌伴门静脉癌栓的降期治疗

肝细胞癌伴门静脉癌栓发生率高,病情进展快,现有治疗方法有限且效果不佳。虽然国外指南推荐索拉非尼为唯一治疗手段,但临床研究显示部分患者,尤其是伴癌栓侵犯至门静脉一级或二级分支的患者(程氏分型Ⅰ/Ⅱ型),通过手术切除可以取得比其他非手术疗法更好的效果。然而临床实践中相当一部分患者由于病灶范围较广无法根治性切除,或者由于癌栓侵犯到门静脉主干(程氏Ⅲ型),术后癌栓残留可能性高,需要通过降期切除的方法改善预后。研究发现通过新辅助三维适形放疗、经肝动脉钇-90微球放射性栓塞、肝动脉灌注化疗等姑息性治疗方法,部分患者(5.7%~26.5%)可出现门静脉癌栓消退乃至消失、肿瘤体积缩小、卫星灶消失等现象,从而使病灶降期,提高手术切除率并延长患者生存时间。多学科综合治疗对于进一步提高肝细胞癌伴门静脉癌栓患者的降期切除率至关重要。     

A new classification for hepatocellular carcinoma with portal vein tumor thrombus

Background/purpose

We aimed to correlate the survival of patients with hepatocellular carcinoma (HCC) with macroscopic portal vein tumor thrombus (PVTT) who underwent partial hepatectomy with or without portal thrombectomy with our PVTT classification. Currently, different staging systems for HCC are widely used in clinical practice. However, they lack the refinement in giving prognosis and guiding surgical treatment once macroscopic PVTT is present.

Methods

A retrospective study was carried out, in a single tertiary center, from January 2001 to December 2004 on 441 patients who underwent partial hepatectomy with or without portal thrombectomy for HCC with macroscopic PVTT. Overall survival was examined to determine whether it was correlated with our PVTT classification, and with the TNM staging, Cancer of the Liver Italian Program (CLIP) scoring system, and the Japan Integrated Staging (JIS) scoring system.

Results

With our PVTT classification, the numbers (percentages) of patients with types I, II, III, and IV PVTT were 144 (32.7%), 189 (42.9%), 86 (19.5%), and 22 (5.0%), respectively. The corresponding 1-, 2-, and 3-year overall survival rates for types I to IV PVTT were 54.8, 33.9, and 26.7%; 36.4, 24.9, and 16.9%; 25.9, 12.9, and 3.7%; and 11.1, 0, and 0%, respectively (log-rank of the survival curves P?<?0.0001). Using the TNM system, the majority of patients were classified as stage III (n?=?379 or 85.9%). Similarly, the majority of patients (n?=?388 or 88.0%) were classified as having CLIP scores of 2 (n?=?143, or 32.4%), 3 (n?=?171, or 38.8%), and 4 (n?=?74, or 16.8%). The 1-, 2-, and 3-year overall survivals for these 3 CLIP scores were very similar. Using the JIS score, the majority of patients (n?=?372 or 84.4%) were classified with a JIS score of 2. The 1-, 2-, and 3-year overall survivals of patients with a JIS score of 2 were worse than those of the patients with a JIS score of 1 (this was expected) as well as being worse than those with a JIS score of 3 (this was unexpected). Thus, the latter 3 systems of classification were not refined enough, and they were inadequate for stratifying HCC with macroscopic PVTT treated with partial hepatectomy with or without thrombectomy.

Conclusions

In patients with HCC with macroscopic PVTT treated by partial hepatectomy with or without thrombectomy, our PVTT classification better stratified and predicted prognosis than the TNM staging, CLIP scoring system, and JIS scoring system, which were unrefined and inadequate for this group of patients.     

肝细胞癌伴门静脉癌栓的手术治疗

门静脉癌栓(PVTT)是肝细胞癌(简称肝癌)重要的生物学特性,也是其严重并发症和转移方式,手术切除仍然是目前肝癌伴PVTT最有效的治疗方法。介绍了肝癌伴PVTT手术治疗的历史与现状、PVTT形成的解剖学基础、PVTT分型、手术适应证、术式选择以及手术疗效评价。认为在循证医学的基础上建立个体化多学科治疗模式,可能是肝癌伴PVTT治疗的发展方向。     

Long-term surviving patient with inferior vena cava tumor thrombus and extrahepatic metastasis after spontaneous ruptured hepatocellular carcinoma

We present a case of long-term survival in a patient with inferior vena cava tumor thrombus (IVCTT) and extrahepatic metastasis after resection for spontaneous ruptured hepatocellular carcinoma (HCC). The patient was a 73-year-old Japanese man previously diagnosed with chronic hepatitis B. He was referred to our emergency room and diagnosed with spontaneous ruptured HCC. The patient was immediately treated with transcatheter arterial embolization, and we then performed second-stage hepatic resection 50 days later. Although des-gamma-carboxy prothrombin was reduced to a normal level after hepatectomy, it gradually increased and computed tomography showed a disseminated tumor in the diaphragm near S2 of the liver with IVCTT and right atrium tumor thrombus. Recurrent HCC was treated with monthly transcatheter arterial infusion chemotherapy (TAI) and conformal radiotherapy (RT) of 40 Gy. After TAI and RT procedures, the disseminated tumor and IVCTT completely disappeared. Four years after TAI and RT procedures, the tumors were well controlled with no local recurrence. About 6−7 years after spontaneous ruptured HCC, lung metastasis and spleen metastasis were detected and resected, respectively. The patient is still alive and doing well over 7 years after spontaneous ruptured HCC.