Portal vein involvement in hepatocellular carcinoma: dynamic CT features

The authors conducted a retrospective examination of 62 hepatocellular carcinomas, taking dynamic CT scans of selected sections after an intravenous contrast bolus. The proximal portal vein was involved in 40% of cases and the distal segment in 16%. Angiographic correlation was available in 23 patients. CT signs of main or lobar portal vein involvement included (a) hypodensity and enlargement, (b) periportal arterial hypervascularization surrounding the hypodense intraluminal region, (c) nonvisualization of the lobar portal vein, (d) arterioportal shunting, and (e) differences in lobar attenuation. The characteristic appearance of tumor within the portal vein was noted in many cases; in others, distinction between tumor and bland thrombus could not be made. Peripheral portal vein obstruction was suggested when a small, hypervascular tumor became hypodense during the portal phase of CT. The frequency and significance of these CT signs of portal vein involvement are discussed.     

Portal vein embolization with N-butyl cyanoacrylate before partial hepatectomy in patients with hepatocellular carcinoma and underlying cirrhosis or advanced fibrosis

PURPOSE: To describe the safety, complications, and liver regeneration associated with the left liver after embolization of the right portal vein (PV) in patients with hepatocellular carcinoma (HCC) developed in the setting of advanced liver fibrosis and cirrhosis. MATERIALS AND METHODS: Forty patients (31 men, nine women; mean age, 62 years) with HCC underwent PV embolization over a 4-year period. Embolization was performed from a left PV percutaneous access with use of n-butyl cyanoacrylate (NBCA) mixed with iodized oil. Computed tomography (CT) volumetry was performed before and 1 month after PV embolization to measure the left lobe volume as well as the functional liver ratio defined by the ratio between the left lobe and the total liver volume minus tumoral volume. PV pressure and liver enzyme levels were compared before and 1 month after the procedure and complications were registered. Factors potentially affecting regeneration (age, sex, diabetes, chemoembolization, functional liver ratio before PV embolization, and Knodell histologic score) were evaluated by one-way and stepwise regression analysis. RESULTS: PV embolization could be achieved successfully in all cases. Two patients had partial PV thrombosis on the 1-month follow-up CT and two patients developed transient ascites after PV embolization. The left lobe volume increase was 41% +/- 32% after PV embolization and the functional liver ratio increased from 28% +/- 10% to 36% +/- 10% (P < .0001). Hypertrophy of the left lobe was greater in patients with a low functional liver ratio before PV embolization and those with an F3 fibrosis score. Other factors had no influence on left lobe regeneration. CONCLUSION: PV embolization with use of NBCA is feasible in patients with advanced fibrosis and cirrhosis. Hypertrophy of the left lobe of the liver after PV embolization has a statistically significant correlation with lower functional liver ratio and lower degrees of fibrosis.     

Role of curative treatment in patients with intermediate-stage hepatocellular carcinoma

Purpose

To retrospectively evaluate the role of curative treatment in patients with intermediate-stage hepatocellular carcinomas (HCCs), and to identify the subgroup having benefit from curative treatment.

Methods

From April 2000 to December 2014, 100 patients with intermediate-stage HCCs underwent either curative treatment (hepatectomy: n = 23, radiofrequency ablation (RFA); n = 29, both: n = 4) or transarterial chemoembolization (TACE): n = 44) as initial treatments for HCCs. Overall survival, influence of treatment allocation on prognosis, and factors affecting treatment allocation were evaluated.

Results

The 5-year survival rate was 59.2% [95% confidence interval (CI) 51.6–66.8%] in the curative group, and 25.1% (95% CI 11.5–38.7%) in the TACE group. Treatment allocation was the only significant prognostic factor (p = 0.014, hazard ratio: 0.382, 95% CI 0.177–0.821). The curative group consisted of more patients with Child-Pugh A (p = 0.0016) than the TACE group, a tumor number of 3 or fewer (p < 0.0001), a unilobar tumor location (p = 0.02), within 4 of 7 cm criterion (p = 0.001), and within up-to-7 criterion (p = 0.04). Child-Pugh A, within the 4 of 7 cm criterion, and a unilobar tumor location were significantly linked with treatment allocation in multivariate analysis.

Conclusions

Curative treatment can prolong survival in selected patients with intermediate-stage HCCs.

     

Preliminary clinical experience with laser-induced interstitial thermotherapy in patients with hepatocellular carcinoma

The purpose of this preliminary study was to evaluate whether laser-induced interstitial thermotherapy (LITT) may be used for palliative treatment of localized hepatocellular carcinomas (HCC). We applied LITT to two patients suffering from unresectable localized hepatocellular carcinomas of different sizes (2.5 and 4 cm). LITT was performed with an Nd:YAG laser (1,064 nm) at 5 W laser power (15–20 minutes). Thermometry during LITT was performed by MRI using a temperature-sensitive T1-weighted fast low-angle shot (FLASH) sequence. Follow-up for local tumor control was performed by MRI and ultrasound. LITT was well tolerated and no adverse events occurred during or after LITT; no secondary liver lesions were seen in the follow-up (11 or 12 months, respectively). Only minimal tumor growth was observed in the larger HCC (from 4 to 5 cm), whereas the smaller HCC remained unchanged in size during 11 months of follow-up. We conclude that LITT might be an effective minimally invasive palliative treatment option for patients with small unresectable HCC.     

肝切除手术相关因素对肝细胞癌预后的影响

目的 分析影响肝细胞癌(HCC)患者预后的手术相关因素.方法 1991年1月～2002年6月实施根治性肝切除、随访资料和临床资料完整的HCC患者234例,回顾性分析医源性肝癌被膜破裂、术中出血量、输血量、手术持续时间、手术大小程度、肝门阻断次数和术后并发症(胆漏、切口感染、胸腔积液)等手术相关因素对患者长期存活的影响.生存时间比较采用Log-rank检验,各因素间的相关性采用双变量相关分析.结果 医源性肝癌被膜破裂、术中出血量、输血量和手术持续时间可影响HCC预后(P＜0.05).输血量与手术大小程度呈正相关(P＜0.05),但出血量与后者无明显相关性(P＞0.05).结论 减少出血和输血量、缩短手术时间、避免肝癌被膜破裂是改善HCC预后的重要举措.     

Helical CT findings in patients with hepatocellular carcinoma treated with percutaneous ablation procedures

Nonsurgical treatment of hepatocellular carcinoma is used worldwide as a result of the early detection and slow growth of this tumor in patients with chronic liver disease. Multiple-phase helical computed tomography is a commonly used method for evaluating the main features related to percutaneous ablation procedures: nodular changes, tumor necrosis, parenchymal changes, complications, and tumor recurrence. Knowledge of all features recognizable after local ablation therapy is mandatory to avoid diagnostic pitfalls and to optimally assess treatment response.     

Percutaneous metallic stents in patients with obstructive jaundice due to hepatocellular carcinoma

PURPOSE: To evaluate the technical success and clinical efficacy of percutaneously placed self-expandable metallic stents in patients with obstructive jaundice due to hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Fifteen men (mean age, 59.3 years) with obstructive jaundice resulting from HCC were treated with self-expandable metallic stents (28 stents in 19 sessions). The authors evaluated the technical success, clinical success (decrease of 30% of total serum bilirubin level or <2 mg/dL [34.2 micromol/L]), treatment efficacy according to lowest total serum bilirubin level, complications, and duration of stent patency. RESULTS: Technical success was achieved in all patients. Clinical success was achieved in 11 of the 15 patients (73%). After stent placement, seven patients (47%) had a low bilirubin level (<2 mg/dL [34.2 micromol/L]), three (20%) had an intermediate bilirubin level (2-10 mg/dL [34.2-171 micromol/L]), and five (33%) had a high bilirubin level (>10 mg/dL [171 micromol/L]). A low bilirubin level was achieved in all patients with Child-Pugh A disease and stage T2 or T3 HCC. Major complications such as hemobilia necessitating transfusion (n=1) or abscess formation (n=1) occurred in two of the 19 sessions (10%). The overall mean stent patency was 149.8 days (range, 12-790 days). The mean stent patency in patients with Child-Pugh class A disease (257.8 days) was significantly longer than that of patients with Child-Pugh class B and C disease (123.2 and 63 days, respectively) (P<.05). CONCLUSIONS: The percutaneous placement of a self-expandable metallic stent is a feasible and effective palliative treatment for patients with obstructive jaundice resulting from HCC, especially for those with Child-Pugh class A disease and stage T2 or T3 HCC.     

Selective and sequential transarterial chemoembolization: survival in patients with hepatocellular carcinoma

Purpose

To assess the survival time of patients with HCC following transarterial chemoembolization performed in a highly selective and sequential way.

Patients and methods

124 HCC patients (102 male, 22 female; mean age 63 ± 11 years) treated with selective and sequential chemoembolization at a single center were included. Selective chemoembolization was performed through a coaxially introduced microcatheter in a segmental or subsegmental hepatic artery. Treatment was stopped after complete stasis of the blood flow in the tumor-feeding vessel. The primary endpoint of the study was overall survival.

Results

The median overall survival of the entire patient population was 27.2 months (mo) (±8.9 mo, 95% CI 9.8 mo, 44.6 mo). When stratified according to liver function the median survival was 46.1 mo (±9.0 mo; 95% CI 28.5 mo, 63.7 mo) for Child-Pugh A and 11.1 mo (±4.3 mo; 95% CI 2.7 mo, 19.5 mo) for Child-Pugh B (p < .001). The median survival was 46.1 mo (±16.6 mo; 95% CI 13.5 mo, 78.7 mo) for BCLC stage A, 19.7 mo (±2.6 mo; 95% CI 14.6 mo, 24.8 mo) for BCLC stage B, and 14.4 mo (±5.0 mo; 95% CI 4.5 mo, 24.3 mo) for BCLC stage C (p < .01).

Conclusion

Selective and sequential chemoembolization offers long survival times in patients with HCC. Those patients with preserved liver function benefit more than patients with limited liver reserve.     

原发性肝癌晚期疼痛的评估及护理

疼痛是晚期癌症患者最主要、最难以忍受的症状之一，发生率较高，30％为重度癌痛，疼痛从心理、生理、精神等多方面影响患者的生活质量。为了减轻癌症病人的疼痛，提高对疾病的治疗效果，对癌痛病人的止痛护理尤为重要。因此，掌握正确的评估方法，实施有效的止痛措施和完善的护理，对提高癌症疼痛患者生活质量，有着重要的意义。因此，需要护士具备处理癌痛的多方知识，掌握正确评估方法和治疗技术及恰当的护理。     

Radioembolisation in patients with hepatocellular carcinoma that have previously received liver-directed therapies

Purpose

Radioembolisation is part of the multimodal treatment of hepatocellular carcinoma (HCC) at specialist liver centres. This study analysed the impact of prior treatment on tolerability and survival following radioembolisation.

Methods

This was a retrospective analysis of 325 consecutive patients with a confirmed diagnosis of HCC, who received radioembolisation with yttrium-90 resin microspheres at eight European centres between September 2003 and December 2009. The decision to treat was based on the clinical judgement of multidisciplinary teams. Patients were followed from the date of radioembolisation to last contact or death and the nature and severity of all adverse events (AEs) recorded from medical records.

Results

Most radioembolisation candidates were Child-Pugh class A (82.5%) with multinodular HCC (75.9%) invading both lobes (53.1%); 56.3% were advanced stage. Radioembolisation was used first-line in 57.5% of patients and second-line in 34.2%. Common prior procedures were transarterial (chemo)embolisation therapies (27.1%), surgical resection/transplantation (17.2%) and ablation (8.6%). There was no difference in AE incidence and severity between prior treatment subgroups. Median (95% confidence interval [CI]) survival following radioembolisation was similar between procedure-naive and prior treatment groups for Barcelona Clinic Liver Cancer (BCLC) stage A: 22.1 months (15.1–45.9) versus 30.9 months (19.6–46.8); p?= 0.243); stage B: 18.4 months (11.2–19.4) versus 22.8 months (10.9–34.2); p?= 0.815; and stage C: 8.8 months (7.1–10.8) versus 10.8 months (7.7–12.6); p?= 0.976.

Conclusions

Radioembolisation is a valuable treatment option for patients who relapse following surgical, ablative or vascular procedures and remain suitable candidates for this treatment.

     

Octreotide scans are positive in a subset of patients with hepatocellular carcinoma

PURPOSE: In vitro data suggest that a proportion of hepatocellular carcinomas express the somatostatin receptor. However, in vivo data are lacking. There has been little reported use of octreotide scans in hepatocellular carcinomas. This study was performed to determine the percentage of positive results of octreotide scanning in patients with hepatocellular carcinoma. MATERIALS AND METHODS: In-111 octreotide scans were performed in the standard manner in eight patients with unresectable hepatocellular carcinoma. Computer fusion imaging of the nuclear medicine and computed tomographic scans was performed in selected patients. RESULTS: Five of eight (63%) patients tested had hepatocellular carcinomas that displayed focal tracer uptake. CONCLUSIONS: This is the first report of positive uptake of octreotide scans in patients with hepatocellular carcinoma. These findings may have implications for the treatment of hepatocellular carcinoma with octreotide. Furthermore, these results may broaden the differential diagnosis in patients with positive results of octreotide scanning.     

动脉化疗栓塞辅助手术切除对肝癌患者长期生存的研究

目的 评价动脉化疗栓塞(transarterial chemoembolization,TACE)对可切除肝癌患者生存期的影响.方法 回顾性分析386例因肝癌行部分肝切除术患者的临床资料.全部病例经术后病理证实.根据是否辅以TACE治疗分为TACE组(230例)和非TACE组(156例).TACE组再根据手术与TACE的先后关系分3个亚组:仅术前行TACE者71例为术前TACE组,仅术后行TACE者86例为术后TACE组,术前术后均行TACE者73例为联合TACE组.为比较TACE对肿瘤坏死的影响,术前未行TACE者242例归为A组(非TACE组+术后TACE组),术前行TACE者144例归为B组(术前TACE组+联合TACE组).应用寿命表计算累积生存率,以Kaplan-Meier生存曲线进行生存分析.采用X2检验比较A、B两组肿瘤的坏死率.结果 B组(18/144)较A组(0/242)有较高的肿瘤完全坏死率(P＜0.01).肿瘤完全坏死患者的累积生存率优于不完全坏死者(P＜0.01).患者1、3、5、10年累积生存率:联合TACE组分别为90.4%(66/73)、72.9%(42/73)、51.9%(22/73)和25.4%(2/73),术前TACE组分别为74.0%(50/71)、46.2%(28/71)、27.3%(5/71)和0(0/71),术后TACE组分别为88.0%(73/86)、59.6%(39/86)、36.7%(11/86)和0(0/86),非TACE组分别为75.8%(110/156)、63.4%(48/156)、31.0%(13/156)和23.9%(10/156).联合TACE组疗效最好,优于非TACE组及单纯术前TACE组和术后TACE组(P值均＜0.05).术前或术后TACE组累积生存率与非TACE组比较差异无统计学意义(P值均＞0.05).结论 术前联合术后TACE辅助手术部分肝切除可提高肝癌患者的累积生存率,仅单一术前或术后TACE对患者的远期生存无显著影响.     

原发性肝癌伴门脉高压的TIPSS治疗

本文对伴有门脉高压症的５名原发性肝癌（ＰＨＣ）患者的ＴＩＰＳＳ治疗进行报道。在ＴＩＰＳＳ术中，成功地建立了肝内门腔分流道，未发生肝内病变的误穿；术后患者的门脉压力得到下降，食管胃底静脉曲张得以减轻和消失。４名曾于ＴＩＰＳＳ术前有上消化道出血者术后有３例未再出血。作者认为：ＰＨＣ不是ＴＩＰＳＳ治疗门脉高压症的禁忌症；ＰＨＣ患者经ＴＩＰＳＳ治疗后，由于避免了门脉高压合并症的出现，因此生活质量得以提高。     

Clinical trial of cisplatin-conjugated gelatin microspheres for patients with hepatocellular carcinoma

Purpose

We report our initial experience with the transarterial chemoembolization (TACE) of unresectable hepatocellular carcinoma (HCC) using cisplatin-conjugated gelatin microspheres (Cis-GMS).

Methods and material

Nineteen patients with 25 HCC nodules (mean diameter 23.0?mm) were treated by selective TACE using 50- to 100-??m Cis-GMS. Tumor necrosis and postembolization syndrome were assessed during the follow-up. The tumor response was evaluated on contrast-enhanced computed tomography images at 1 and 3?months after TACE using Cis-GMS.

Results

All procedures were technically successful in all patients; following the TACE using Cis-GMS, there were no major complications, and postembolization syndrome was minimal. At the 1-month follow-up, the response rate was 12 of the 25 (48%) and 21 of the 25 (84%) HCC nodules based on RECIST 1.1 and EASL criteria, respectively; at the 3-month follow-up, it was 10 of the 25 (40%) and 14 of the 25 (56%) HCC nodules, respectively.

Conclusion

Our initial experience with using Cis-GMS for TACE suggests that these drugs may represent an optimal treatment option for the treatment of advanced HCC and that the use of gelatin microspheres loaded with chemotherapeutic agents warrants further study.