肝癌门静脉癌栓的介入治疗

肝癌合并门静脉癌栓(PVTT)的治疗仍是医学难题,既往一直被视为手术禁忌,近年随着介入医学的进步,发展了多种微创治疗方法,取得了可喜的疗效,使肝癌并PVTT由不可治变为部分可治,展现了介入方法治疗肝癌并PVTT的乐观前景.本文就当前针对门静脉癌栓的介入治疗方法,技术要点及各种介入治疗方法的初步疗效进行了综述.为进一步的临床规范化综合治疗肝癌并门静脉癌栓提供参考.     

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。     

预测钇-90放射栓塞术治疗伴门静脉浸润的肝细胞癌反应的预后分层

【据《J Hepatol》2018年1月报道】题：预测钇-90放射栓塞术治疗伴门静脉浸润的肝细胞癌反应的预后分层（作者Spreafico C等）肝细胞癌（HCC）是全球性的健康问题,且很大比例伴有门静脉癌栓（PVTT）。钇-90经动脉放射栓塞术（TARE）是一种通过选择性动脉内注射微珠（Yttrium-90）所表现的一种短距离放射治疗,其特点是穿透性有限,对周围组织的损伤有限。对于伴有PVTT的HCC患者,在治疗上有很好的疗效。来自于意大利米兰国家肿瘤研究所的Spreafico等连续收集了6年中经TARE治疗伴PVTT的HCC患者共120例,     

伽玛刀治疗门静脉癌栓32例疗效观察

目的探讨伽玛刀治疗门静脉癌栓（PVTT）的效果。方法对32例肝细胞癌伴PVTT患者实行伽玛刀治疗。采用50%～60%等剂量曲线包绕临床靶区。单次周边剂量为4.5～5.0Gy,共10～12次,总量介于50～54Gy之间,观察疗效。结果在伽玛刀治疗结束4周后,10例（31.3%）患者癌栓完全缓解,8例（25%）部分缓解,12例（37.5%）稳定,2例（6.3%）进展,总有效率为93.7%;27例AFP阳性患者经治疗后20例AFP下降至正常。1年累积生存率为48.1%,中位生存期为10.2个月。结论伽玛刀是治疗门静脉癌栓的有效方法,能延长患者的生存期。     

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。     

肝癌致门静脉癌栓80例表观扩散系数及扩散加权成像表现分析

目的探讨肝癌致门静脉癌栓(PVTT)80例患者的表观扩散系数(ADC)及扩散加权成像(DWI)表现。方法选取我院2015年6月—2018年6月收治的肝癌致PVTT患者80例,将其作为PVTT组,选取同期收治的单纯肝癌患者80例,作为无PVTT组。所有患者均于入院后接受常规MRI探查,并行DWI检查,测定两组肝癌病灶的ADC值,绘制受试者工作特征曲线(ROC)分析ADC值对肝癌致门静脉癌栓的预测价值。测定PVTT组门静脉癌栓病灶的ADC值,利用Pearson线性相关分析PVTT组患者肝癌病灶、癌栓病灶ADC值的相关性。分析PVTT组肝癌病灶、门静脉癌栓病灶的DWI、ADC表现。结果 PVTT组肝癌病灶的ADC值为(1.18±0.21)×10~(-3) mm~2/s,显著低于无PVTT组的(1.42±0.34)×10~(-3) mm~2/s(P0.05)。ADC值预测肝癌致PVTT的曲线下面积为0.648。PVTT组癌栓病灶的ADC值为(1.02±0.14)×10~(-3) mm~2/s,显著低于PVTT组肝癌病灶的(1.18±0.21)×10~(-3) mm~2/s(P0.05)。Pearson线性相关分析提示PVTT组肝癌病灶与癌栓病灶的ADC值呈正相关(P0.05)。在80例肝癌致门静脉癌栓患者中,经MRI检出肝癌病灶92个,癌栓84支。经DWI提示在肝癌病灶中,高信号89个,低信号3个,经ADC提示高信号21个,低信号71个。经DWI提示在癌栓中,高信号80个,低信号4个,经ADC提示高信号20个,低信号64个。结论与单纯肝癌患者相比,肝癌致PVTT患者的肝癌病灶ADC值明显下降,其ADC值对PVTT发生风险有一定预测价值,且肝癌致PVTT患者的肝癌病灶、癌栓病灶ADC值有较强相关性。     

粒细胞和淋巴细胞比值与HBV相关原发性肝癌伴门静脉癌栓发生远端转移的相关性研究

[目的]分析比较乙型肝炎病毒(hepatitis B virus,HBV)相关原发性肝癌(HBV-PLC)伴门静脉癌栓(PVTT)患者及HBV-PLC伴PVTT发生远端转移患者的临床检测指标,寻找粒细胞和淋巴细胞比值(N/L)与HBV-PLC伴PVTT发生远端转移的关系。[方法]回顾性收集首都医科大学附属北京地坛医院2012年1月~2015年6月初次确诊为HBV-PLC伴PVTT的患者245例(未转移组)及HBV-PLC伴PVTT发生远端转移的患者122例(转移组),采集患者的临床信息,将患者人口学特征及生化指标采用SPSS20.0进行描述性分析,并通过logistic回归分析筛选出发生远端转移的独立危险因素。[结果]未转移组与转移组比较,N/L≥1.787、红细胞计数、血小板计数为其独立预测因素,转移组患者的N/L明显升高。[结论]N/L升高是HBV-PLC伴PVTT患者发生远端转移的独立危险因素,并可以作为HBV-PLC伴PVTT发生远端转移的预测因子。     

腔内植入125Ⅰ粒子条联合经肝动脉化疗栓塞术治疗肝癌合并广泛性门静脉栓的效观察

目前,原发性肝癌(HCC)患者的5年生存率尚不到10％.HCC易侵犯门静脉形成癌栓,几率高达30.0％～60.2％[1].门静脉癌栓(portal vein tumor thrombus,PVTT)形成被认为是影响HCC预后的独立因素[2].我科自2008年采用腔内植入125Ⅰ粒子条及支架联合经肝动脉化疗栓塞术(transcatheter arterial chemoembolization,TACE)治疗HCC合并门静脉主干癌栓取得了良好的疗效[3].但该疗法要求患者的门静脉二级分支血流必须通畅,部分晚期原发性肝癌患者往往出现广泛性PVTT,因门静脉二级分支血管闭塞,或癌栓超过肠系膜上静脉或脾静脉,无法放置内支架.故我们采用B超引导下经皮门静脉腔内125Ⅰ粒子条联合TACE治疗HCC合并PVTT.     

肝细胞癌伴门静脉癌栓的介入综合治疗

伴门静脉癌栓(PVTT)的肝细胞癌(HCC)常见于进展期肝癌,PVTT可引起肿瘤播散、肝功能衰竭和门静脉高压,从而导致顽固性腹水、静脉曲张破裂和肝性脑病,严重影响肝癌患者预后。根据巴塞罗那临床肝癌分期(BCLC),伴PVTT的进展期HCC,索拉非尼被推荐为一线治疗方案,但由于其疗效有限且价格昂贵限制了它在国内的应用。而介入治疗以其微创、可重复性等优点在临床得到广泛应用,并取得一定的疗效。目前主要应用的介入治疗方法包括:经肝动脉灌注化疗术(HAIC)、经肝动脉化疗栓塞术(TACE)、TACE联合索拉非尼、TACE联合消融术、TACE联合适形放疗、TACE联合门静脉支架、门静脉粒子条置放术、经颈静脉肝内门体分流术(TIPS)等。最后指出多种方法综合治疗有望取得较好疗效。     

肝动脉栓塞化疗序贯三维适形放射治疗原发性肝癌伴门静脉癌栓

门静脉癌栓(PVTT)是原发性肝癌(PHC)的重要生物学行为,是影响PHC患者预后的重要因素,其发生率和病死率均较高。PHC合并PVTT首选的治疗手段是手术切除原发灶和癌栓。肝动脉栓塞化疗(TACE)对于不能手术或晚期PHC患者有一定的疗效,近年来,三维适形放疗(3- DCRT)治疗PVFT有较好的疗效。本研究旨在通过对TACE与TACE序贯3-DCRT两种治疗方法的疗效比较,为PHC合并PVTT患者非手术治疗方法的选择提供临床帮助。一、资料与方法1.病例选择:病例纳入依据中国抗癌协会肝癌专业委     

The immunoneuroendocrine role of melatonin

Abstract: A tight, physiological link between the pineal gland and the immune system is emerging from a series of experimental studies. This link might reflect the evolutionary connection between self-recognition and reproduction. Pinealectomy or other experimental methods which inhibit melatonin synthesis and secretion induce a state of immunodepression which is counteracted by melatonin. In general, melatonin seems to have an immunoenhancing effect that is particularly apparent in immunodepressive states. The negative effect of acute stress or immunosuppressive pharmacological treatments on various immune parameters are counteracted by melatonin. It seems important to note that one of the main targets of melatonin is the thymus, i.e., the central organ of the immune system. The clinical use of melatonin as an immunotherapeutic agent seems promising in primary and secondary immunodeficiencies as well as in cancer immunotherapy. The immunoenhancing action of melatonin seems to be mediated by T-helper cell-derived opioid peptides as well as by lymphokines and, perhaps, by pituitary hormones. Melatonin-induced-immuno-opioids (MHO) and lymphokines imply the presence of specific binding sites or melatonin receptors on cells of the immune system. On the other hand, lymphokines such as -γ-interferon and interleukin-2 as well as thymic hormones can modulate the synthesis of melatonin in the pineal gland. The pineal gland might thus be viewed as the crux of a sophisticated immunoneuroendocrine network which functions as an unconscious, diffuse sensory organ.     

Response of rat pineal melatonin to calcium, magnesium, and lithium is circadian stage dependent

Abstract: Herein we documented the response of pineal melatonin production to electrolytes known to be effective on pineal function in view of a possible circadian stage dependence. We studied the release of melatonin by perifused rat pineal glands at 2 different circadian stages corresponding to the middle of the light and dark periods, i.e., respectively, 7 and 19 HALO (Hours After Light Onset, L:D = 12:12). The initial efflux rates were, as expected, much higher in the perifusates of glands removed from rats sacrificed during the dark phase than of those removed during the light phase. After 3 hr of perifusion, melatonin release reached similar levels which were found constant up to the 8th hr of perifusion, whatever the circadian stage. Perifusion of the glands with physiological concentrations for the rat of calcium (5.2 mmol/1) and magnesium (1.34 mmol/1) resulted in a stimulatory effect on the pineal glands removed from rats sacrificed in the middle of the dark period (19 HALO), whereas no effects were observed on the pineal glands removed from rats sacrificed during the light (7 HALO). Lithium (0.28 and 0.55 mmol/1) was ineffective on melatonin release in pineal glands removed 7 and 19 HALO. Our results show differences in the initial efflux rates of melatonin and in the response of perifused pineal glands to calcium and magnesium according to the circadian stage.     

Changes in connexin43, the gap junction protein of astrocytes, during development of the rat pineal gland

Abstract: The abundance of gap junctions between rat pineal astrocytes formed by connexin43 (Cx43) was studied during development. Levels and distribution of Cx43 were measured by immunoblotting and indirect immunofluorescence, respectively. The amount of Cx43 in cells located within the gland was low until about the 7th postnatal day and increased to adult values between the 14th and 21st days postpartum. Although astrocytes, recognized by their vimentin immunoreactivity, were scarce before birth, they were abundant by the 7th postnatal day suggesting that the low levels of Cx43 found at this age corresponded to a low expression of this protein. Localization of the immunoreactivity to Cx43 and vimentin showed a close correlation, indicating that mature or immature pineal astrocytes form gap junctions made of Cx43. Since Cx43 levels attained their adult values at about the time the innervation and the functional state of the gland reached maturity (2–3 weeks after birth), it is proposed that astrocyte gap junctions are involved in the function of the adult rat pineal gland.     

Conservative management of perforated duodenal diverticulum： A case report and review of the literature

Duodenal diverticula are a relatively common condition. They are asymptomatic, unless they become complicated, with perforation being the rarest but most severe complication. Surgical treatment is the most frequently performed approach. We report the case of a patient with a perforated duodenal diverticulum, which was diagnosed early and treated conservatively with antibiotics and percutaneous drainage of secondary retroperitoneal abscesses. We suggest this method could be an acceptable option for the management of similar cases, provided that the patient is in good general condition and without septic signs.     

Presence of immunoreactive growth hormone and prolactin in the ovine pineal gland

Abstract: The use of antisera raised against bovine growth hormone (GH) and ovine prolactin (PRL) enabled the detection of related immunoreactive (ir) sequences of proteins in ovine pineal tissue. The isolation of PRL-like ir-material was accomplished using a 0.25 M ammonium sulphate (pH 5.5) extraction followed by ethanol precipitation, whereas the resulting 2.0 M ammonium sulphate (pH 7.0) precipitate contained a GH-like immunoreactivity. Gel chromatography of the GH-like immunoreactivity (Sephadex G-100) indicated the presence of several GH-like fragments ranging in the M_r range of 7,000 to 55,000. Analyses of the PRL-like ir-material found in pineal tissue on HPLC using a TSK 545-DEAE column led to the resolution into a single peak of immunoreactivity. A single peak of activity was also observed following chromatofocusing and hydrophobic interaction chromatography of the ir-peak from the TSK 545-DEAE column. The PRL-like ir-material inhibited the binding of [¹²⁵I]ovine PRL-S14 to anti-ovine PRL antibodies without showing an affinity for binding to anti-rat PRL or anti-bovine GH antibodies. Scatchard analysis of the binding of pineal PRL-like ir-material and pituitary ovine PRL-S14 to liver membranes from day-20 pregnant rats revealed similar affinity constants (K_a of 4.7 ± 0.2 × 10⁹ M^-1). In addition, the replication of Nb 2 Node rat lymphoma cells was stimulated by pineal PRL-like ir-material, an effect known to be specific for lactogenic hormones. The pineal PRL-like immunoreactivity appeared on sodium dodecyl sulfate polyacrylamide gels as a single major band of M_r 24,000. The functional status of PRL-and GH-like ir-material in the ovine pineal remains to be determined, but evidence is presented that the overall protein synthesis rate of the rat pineal responded to circulating concentrations of PRL.     

Microbiology of human immunodeficiency virus anorectal disease

PURPOSE: Individuals who are seropositive for the human immunodeficiency virus are at high risk for opportunistic infection and anorectal disorders. Little prospective information is available regarding anorectal pathogens in these patients. METHODS: One hundred sixty-three HIV-seropositive patients presented to the colorectal clinic between 1989 and 1992. Forty-seven (29 percent) patients were thought to have an infectious process and were prospectively studied using a standardized multiculture protocol. RESULTS: Mean age was 33 (range, 19–59) years. All were male; high-risk behavior accounted for 87 percent of HIV transmissions. Presenting complaints included anorectal pain (79 percent), pus per anum (28 percent), and blood per anum (26 percent). Examination revealed perianal tenderness (60 percent), condyloma (38 percent), perianal ulcers (38 percent), and anal fissures (34 percent). Sixty-six sets of cultures were performed; 28 patients had one set, 15 had two sets, and 4 had three sets. Thirty-two of these 47 patients (68 percent) had positive cultures including herpes (50 percent), cytomegalovirus (25 percent),Neisseria gonorrhoeae (16 percent), chlamydia (16 percent), acidfast bacilli (2 percent), and others (9 percent). Six of 32 patients with positive cultures had more than one organism cultured. Sixteen (50 percent) patients with positive cultures were treated medically, 8 (25 percent) were treated surgically and 8 (25 percent) were treated with both modalities. Sixty-one procedures were performed on 17 patients for condylomata. Eighteen patients had 20 procedures for abscesses, 50 percent of whom had positive cultures for other than common bowel flora; all improved. Fourteen patients underwent 33 procedures for perianal fistulas.Mycobacterium fortuitum was cultured from one patient who required 13 procedures for abscesses and fistulas. Forty-five (96 percent) patients were followed for an average of 12.5 months ±2.9 SEM (range, 1–94 months). Symptoms were improved or resolved in 22 of 32 (69 percent) patients with positive cultures and in 11 of 13 (84 percent) with negative cultures. CONCLUSIONS: Specific pathogens may often be identified in human immunodeficiency virus-seropositive patients with anorectal disorders if aggressively sought. Although patients without specific pathogens identified may be expected to improve with planned empiric treatment, positive identification allows more directed therapy.