The role of vascular resection and reconstruction in the treatment of hilar cholangiocarcinoma

OBJECTIVE: To evaluate the role of vascular resection and reconstruction in the treatment of hilar cholangiocarcinoma. METHODS: 117 patients with potentially resectable hilar cholangiocarcinoma underwent exploration. Twenty-one patients had exploration or drainage only due to distant metastases, and the other 96 patients received surgical resection. Thirty-one of those had vascular resection and reconstruction, including portal vein resection alone in 21 patients, combined hepatic artery and portal vein resection in 2 and hepatic artery resection alone in 8. Therefore, the patients were divided into four groups: non-surgical resection (21), portal vain resection (21), hepatic artery resection (10) and non-vascular resection (65) and their clinical data were reviewed retrospectively. RESULTS: The hepatic artery resection group had significantly higher perioperative morbidity and mortality rate (80.0% and 20.0%) than non-vascular resection group (16.9% and 1.5%), respectively, (P < 0.05), while no significant difference was found between the portal vein resection alone group and the non-vascular resection group (P > 0.05). Of all resected vessel specimens, vascular wall invasion beyond the adventitia was pathologically confirmed in 82.6% of the portal veins and 50.0% of the hepatic arteries. The 1-, 3- and 5-year survival rates were 59.0%, 34.0%, and 16.0% in the non-vascular resection group, versus 44.0%, 23.0% and 11.0% in the portal vein resection alone group (P < 0.05) and 18.0%, 0 and 0 in the hepatic artery resection group (P < 0.01), respectively, with a significant difference among the three groups. The 1-, 3- and 5-year survival rates in the non-surgical resection group were 13.0%, 0 and 0, respectively, which were similar to those in the hepatic artery resection group. Though a significant difference in survival rates existed between the portal vein resection alone group and non-resected group (P < 0.001), no significant difference was found between the hepatic artery resection group and non-resected group (P > 0.05). CONCLUSION: Both portal vein and hepatic artery resection can improve resection rate for hilar cholangiocarcinoma, and portal vein resection may improve the prognosis in selected patients. However, hepatic artery resection can not improve survival and may even lead to an increase of perioperative morbidity and mortality.     

血管切除及重建治疗肝门部胆管癌

目的 分析肝门部胆管癌患者的预后及术后并发症的发生率,探讨血管切除及重建在肝门部胆管癌治疗中的价值.方法 对117例行手术探查的肝门部胆管癌患者病例资料进行回顾性分77析.结果术后病理检查提示,在切除的血管标本中,有82.6%的门静脉血管外膜和50.O%的肝动脉血管外膜被肿瘤侵犯.无血管切除组吻合口瘘和肝功能衰竭的发生率与肝动脉切除组比较,差异有统计学意义(P＜0.05),而与单纯门静脉切除组比较,差异无统计学意义(P＞0.05).无血管切除组患者的1、3、5年生存率分别为59.0%、34.0%和16.0%,与单纯门静脉切除组和肝动脉切除组比较,差异有统计学意义(P＜0.05);非手术切除组患者的1、3、5年生存率分别为13.O%、0和0,与单纯门静脉切除组比较,差异有统计学意义(P＞0.叭),而与肝动脉切除组比较,差异无统计学意义(P＞0.05).结论 联合门静脉切除和肝动脉切除均能提高肝门部胆管癌的根治切除率.门静脉切除及重建,不仅能改善部分患者的预后,也不增加手术风险;而肝动脉切除及重建对患者的预后无明显影响,但增加了手术风险.     

肝外胆管癌术后辅助放化疗的现况分析

近年来,肝外胆管癌的发病率逐年递增。因其易侵犯周围肝动脉、肝静脉、门静脉,且根治性切除率低,预后较差,即使早期完成根治术,5年生存率仍不足30%。术后辅助治疗能否改善肝外胆管癌的预后一直是研究的热点及争议点,本文将结合最新的研究进展,讨论肝外胆管癌术后辅助治疗的方案,分析术后辅助治疗对于肝外胆管癌预后的意义。     

Adjuvant therapy of colon cancer: a review

Colon cancer is a common cause of cancer-related mortality. Complete surgical resection of the primary tumor and/or select metastatic lesions can be curative in many patients. The risk of recurrence after resection can be predicted by pathologic staging. Large prospective randomized trials over the past 2 decades have clearly shown an increased overall survival for patients with resected stage III colon cancer who are treated with adjuvant 5-fluorouracil-based chemotherapy. The benefit of adjuvant chemotherapy for patients with stage II disease remains controversial. There is indirect evidence to support adjuvant chemotherapy after resection of metastatic disease. Locoregional approaches such as radiation, hepatic arterial infusion, or portal vein chemotherapy remain investigational. Adjuvant immunotherapy with monoclonal antibodies is emerging as a therapeutic option that might complement chemotherapy. Future challenges include improving adjuvant chemotherapy with the addition and/or substitution of new agents, resolving which subset of patients with stage II and resected stage IV colon cancer might benefit from therapy, validating the benefit of immunotherapy, and investigating locoregional therapies compared with systemic therapy.     

Reevaluation of prognostic factors for survival after liver resection in patients with hepatocellular carcinoma in a Japanese nationwide survey

BACKGROUND: Advances in the diagnosis and surgical treatment of hepatocellular carcinoma (HCC) have improved the prognosis for patients with HCC who undergo liver resection. The objective of this study was to evaluate prognostic predictors for patients with HCC who underwent liver resection in a Japanese nationwide data base. METHODS: In this study, the authors analyzed 12,118 patients with HCC in a Japanese nationwide data base who underwent liver resection between 1990 and 1999 and compared them with a previous analysis of patients between 1982 and 1989. All patients were evaluated for prognostic factors. RESULTS: During the last decade, the increases in patients who were without hepatitis B virus surface antigen, who had small tumors, and who had portal vein invasion were noted. The 5-year overall survival rates for patients with HCC improved to 50.5%, compared with < 40% in the previous analysis. A multivariate analysis using a stratified Cox proportional hazards model according to associated liver disease indicated that age, degree of liver damage, alpha-fetoprotein level, maximal tumor dimension, number of tumors, intrahepatic extent of tumor, extrahepatic metastasis, portal vein invasion, hepatic vein invasion, surgical curability, and free surgical margins were independent prognostic predictors for patients with HCC. Operative mortality decreased from 2.3% in 1990-1991 to 0.6% in 1998-1999. CONCLUSIONS: Outcomes and operative mortality rates in patients with HCC improved during the last decade. Age, degree of liver damage, alpha-fetoprotein level, maximal tumor dimension, number of tumors, intrahepatic extent of tumor, extrahepatic metastasis, portal vein invasion, hepatic vein invasion, surgical curability, and free surgical margins were prognostic factors for patients with HCC who underwent liver resection.     

肝细胞癌合并门静脉癌栓外科治疗的疗效观察

目的探讨肝细胞癌合并门静脉癌栓（PVTT）外科治疗的效果。方法对156例肝细胞癌合并门静脉主干或第一分支癌栓的患者,均行肝癌联同门静脉癌栓切除或取栓,其中94例患者术后行肝动脉和（或）门静脉化疗。结果术后3例死于肝功能衰竭,2例死于术后并发症,余术后恢复良好,术后1、3、5年生存率分别为58．1％（86/148）、18．9％（28／148）、5．4％（8／148）。结论肝切除和门静脉切开取栓术是肝细胞癌合并PVTT的有效治疗方法,术后联合肝动脉和（或）门静脉化疗能提高治疗效果,延长患者的生存期。     

常规根治术、门静脉重建和肝动脉重建治疗肝门部胆管癌的安全性及近期疗效比较

目的 比较常规根治术、门静脉重建和肝动脉重建三种手术方式治疗肝门部胆管癌的安全性及近期疗效。方法 选取108例行胆管癌根治术的肝门部胆管癌患者，根据不同手术方式分为三组：常规根治术组（A组）28例，门静脉重建术组（B组）48例和肝动脉重建术组（C组）32例。比较三组患者围术期的相关指标、术后并发症及术后1年生存率、淋巴结转移等情况。结果 C组手术时间、术中出血量、住院时间及住院费用均高于A组和B组（均P<0.05）。三组患者术后并发症发生率差异无统计学意义（χ ²=0.110, P>0.05）。三组患者淋巴结转移率及术后1年生存率差异均无统计学意义（均P>0.05）。结论 与常规根治术和门静脉重建术比较，肝动脉重建患者近期生存率无差异，可提高根治性手术切除率；但其手术时间和住院时间较长、术中出血量较高、住院花费多。     

Prognostic analysis for treatment modalities in hepatocellular carcinomas with portal vein tumor thrombi

Objective: To assess prognostic aspects of treatment modalities for cases of hepatocellular carcinoma (HCC) with portal vein tumor thrombi (PVTT). Method: 121 treated cases were retrospectively divided into five groups: 1 (liver transplantation); 2 (transcatheter arterial chemoembolization); 3 (hepatectomy plus thrombectomy); 4 (hepatectomy plus thrombectomy combined with adjuvant chemobiotherapy via portal vein); and 5 (conservative treatment). The Kaplan-Meier method with difference in survival estimated by Log-rank test was used to compare between groups. Result: Groups 1-5 had a significantly differing median survival times of 7, 7, 10, 16, 3 months (P<0.05), respectively. One- and three-year survival rates were 30.0% and 10.0%, 20.0% and 0.0%, 47.0% and 22.0%, 70% and 20%, and 12% and 4%. Conclusion: Surgical resection combined with adjuvant chemotherapy via the portal vein is an effective and safe treatment modality for hepatocellular carcinoma with portal vein tumor thrombi.     

肝细胞癌伴门静脉癌栓不同治疗方法的比较

目的 比较肝细胞癌合并门静脉癌栓(ｔｕｍｏｒ ｔｈｒｏｍｂｉ ｉｎ ｐｏｒｔａｌ ｖｅｉｎ,ＰＶＴＴ）不同治疗方法的疗效及其意义。方法 １４７例肝细胞癌伴门静脉主干或第１分支癌栓的住院患者,按不同治疗方法分成４组：保守治疗组（Ａ组,１８例）;肝动脉结扎和（或）肝动脉插管化疗组（Ｂ组,１８例）,术后定期栓塞化疗;肝癌联同ＰＶＴＴ切除组（Ｃ组,７９例）;手术切除＋肝动脉化疗栓塞和（或）肝动脉置管或门静脉     

肝内胆管结石合并肝内胆管癌术后生存率的影响因素分析

目的：探讨影响肝内胆管结石合并肝内胆管癌术后生存率的影响因素。方法：回顾性分析2007年8月至2014年7月本院手术治疗的107例肝内胆管结石合并肝内胆管癌患者的临床资料,分析术后生存率的影响因素。单因素分析采用 Logistic 二元回归模型,筛选有统计学意义的指标纳入 COX 风险回归模型进行多因素分析。结果：Kaplan －Meier 结果显示,107例患者术后1、3、5年总体生存率分别为51．4％、28．0％、9．3％;进行 R0、R1、R2等不同手术方式和仅进行肿瘤活检的患者生存时间有显著性差异（P ＜0．005）。单因素分析结果表明,性别、年龄、肿瘤大小、肿瘤组织分型、肿瘤分化程度、TNM分期、肝内转移与术后生存率无相关性（P ＞0．05）;而淋巴结转移、门静脉浸润、手术切缘和血清 CA19－9水平与术后生存率有相关性（P ＜0．05）;COX 风险回归模型进行多因素分析结果显示,手术切缘和血清 CA19－9水平对患者生存时间的影响差异有统计学意义（P ＜0．05）,是影响术后生存率的独立危险因素。结论：根治性手术切除是肝内胆管结石合并肝内胆管癌最有效的治疗方法,治疗时应特别注意手术切缘和血清 CA19－9水平等影响预后的独立危险因素,以提高生存率。     

Chirurgische Therapie des zentralen Gallengangskarzinoms

Resection represents the only potential curative treatment option for hilar cholangiocarcinoma. Over the past decades the broader application of extended resection including left or right liver resections has led to an increasing surgical radicality and an improvement in the long-term results after surgical treatment. Therefore, presently en bloc hilar resection with right or left hemihepatectomy represents the standard treatment for this tumor entity. In our own strategy we prefer the concept of right trisectionectomy principally with resection of the bifurcation of the portal vein as this operative procedure leads to long-term survival rates of about 60%. By the establishment of new neoadjuvant radiochemotherapy concepts the results after liver transplantation could also be markedly improved with 5 year survival rates over 70% after treatment using the Mayo Clinic protocol. Therefore, hilar cholangiocarcinoma is now a tumor for which a better survival rate can be achieved than for a number of other gastrointestinal carcinomas.     

Radical surgery for hilar cholangiocarcinoma

In the therapy of hilar cholangiocarcinoma, the most favorable survival rates over the long-term are achieved by a surgical concept involving a no-touch-technique, en-bloc-resection and wide tumor-free margins. Currently, these goals can be best achieved by our strategy to combine extended right hepatic resections and principle portal vein resection. In spite of extending resectability to patients with locally advanced tumors, formally curative resections could be performed in 80% of the patients. The 5-year survival rate in these patients is 61%.     

Hepatic arterial infusion chemotherapy (HAIC)--hepatocellular carcinoma

Hepatic arterial infusion chemotherapy (HAIC) has been often selected as a therapeutic option for advanced hepatocellular carcinoma (HCC) with intrahepatic metastases or portal vein thrombosis, which is not eligible for hepatic resection, tumor ablation, or embolization. Among various regimens, HAIC, consisting of 5-fluorouracil (5-FU) in combination with either low-doses of cisplatin (CDDP) or interferon-alpha has been reported to improve the response rates for advanced HCC. As both regimens require the use of an implanted port-catheter system, maintaining the patency of hepatic arteries is an important factor for the intrahepatic drug distribution and the efficacy of HAIC. Recently, a new product, CDDP powder has been also developed for intraarterial use, which adds a new option to HAIC. However, the long-term outcome or the survival benefit remains unclear with HAIC, and it may be significantly affected by liver function and cirrhosis. None of the regimens have been proved to be the standard for HAIC, and prospective multi-center clinical studies with standardized protocol are needed in the future.     

肝动脉栓塞加门静脉置泵治疗晚期原发性肝癌(附160例病例分析)

延长晚期原发性肝癌患者的生存时间，提高生活质量，为二期手术切除创造条件。方法：采用肝动脉栓塞化疗加门静脉置泵，术中栓塞药物为：ADM、泛影葡胺、碘化油及MMC；术后门静脉药泵常用ADM、干扰素注射。结果：术后二个月复查B超，肿瘤缩小明显者（缩小至原肿瘤1／3）者74例，占46％，其中18例施行二期肝癌切除术，160例1年后存活率78．6％，2、3、5年存活率分别为65．6％、43．5％及16．3％。结论：采取肝动脉栓塞加门静脉置泵治疗晚期原发性肝癌160例，效果良好，延长了晚期原发性肝癌的生存时间，为二期手术切除创造了条件。     

Preoperative transcatheter arterial chemoembolization reduces long-term survival rate after hepatic resection for resectable hepatocellular carcinoma.

AIMS: To study the effect of preoperative transcatheter arterial chemoembolization (TACE) on long-term survival after hepatic resection for hepatocellular carcinoma (HCC), we conducted a comparative analysis in 235 HCC patients who underwent hepatic resection with a curative intent. METHODS: We compared clinicopathologic background, mortality, and survival rates after hepatic resection between those who underwent preoperative TACE (n=109) and those who did not (n=126). RESULTS: One hundred and two patients in the TACE group (93.6%) received TACE only once. The mean interval between TACE and hepatic resection was 33.1days. Patients in the TACE group were younger than those in the non-TACE group, and liver cirrhosis and non-anatomical hepatic resection were more prevalent in this group. The 5-year overall survival rate after hepatic resection was significantly lower in the TACE group (28.6%) than in the non-TACE group (50.6%), especially in patients without cirrhosis or with stage I or II tumor. There was no difference between the two groups in mortality or disease-free survival after hepatic resection. Multivariate analysis showed preoperative TACE, preoperative aspartate aminotransferase elevation, and microscopic portal invasion to be independent risk factors for a poor outcome after hepatic resection. CONCLUSIONS: Preoperative TACE should be avoided for patients with resectable HCC, especially for those without cirrhosis or with an early stage tumor.     

Evaluation of the new AJCC/UICC staging system for hepatocellular carcinoma after hepatic resection in Chinese patients

Hepatic resection is considered the treatment of choice for HCC; however, the prognosis of patients after resection of HCC varies widely, depending on the clinicopathologic features. The American Joint Committee on Cancer (AJCC)/International Union Against Cancer (UICC) tumor-node-metastasis (TNM) staging system is widely used evaluating patients with HCC. The current TNM staging for HCC uses pathologic characteristics of tumors, including size, number and location of tumor nodules, presence of vascular invasion, perforation of visceral peritoneum, and invasion of adjacent organs as criteria for T staging. Recently, a simplified AJCC/UICC staging for HCC has been proposed. In addition, the Liver Cancer Study Group of Japan proposed a new simplified staging system based on number of tumor nodules, size of tumors, and invasion into the portal vein, hepatic vein, or bile duct. This article evaluates the prognostic value of the new AJCC/UICC TNM staging and the new Japanese staging in a large cohort of Chinese patients who underwent hepatectomy for HCC in a single institution.     

Study of small hepatocellular carcinomas

In order to evaluate the factors affecting patient survival, 32 patients with a solitary hepatocellular carcinoma (HCC) smaller than 5 cm have been studied. Most patients were diagnosed as having a HCC during the periodic follow-up examinations for their underlying liver disease. For HCCs smaller than 2 cm, ultrasonography demonstrated the highest detection rate compared with CT and angiography. In patients with tumors larger than 2 cm, a portal vein thrombus and/or satellite tumors were frequently recognized, resulting in a lower patient survival rate when compared to those with a smaller HCC. Results have indicated that early detection of such tumors without a portal vein thrombus and/or a satellite tumor, and an adequate hepatic resection, such as segmentectomy or subsegmentectomy, are most important factors HCC patient survival.     

Adjuvant chemotherapy for colorectal hepatic metastases: role of route of administration and timing.

Improved results in the adjuvant and therapeutic treatment of colon cancer has led to renewed interest in the role of adjuvant chemotherapy following liver resection for colorectal hepatic metastases. However, little is known about the most effective method or timing of delivery of adjuvant chemotherapy. Sixty-nine BD-IX rats underwent a right hepatic lobectomy following tumour inoculation via a splenic injection of 10(7) K12/TRb colon cancer cells. The rats were then randomized to receive systemic FUdR (1 mg kg-1 d-1 for 7 d) or regional (hepatic artery or portal vein) FUdR (2 mg kg-1 d-1 for 7 d) immediately or 72 h following tumour injection. On Day 28, a laprotomy was performed, and tumour nodules in the liver were counted. The animals were followed to death, and at autopsy the cause of death from hepatic or extrahepatic metastases was determined. All methods of FUdR infusion were superior to no treatment. Immediate portal vein (PV) FUdR infusion delayed the appearance of hepatic tumour (P = 0.003), changed the cause of death from hepatic to extrahepatic disease (P = 0.019), and prolonged survival (P < 0.05). Infusion of FUdR via the PV 72 h later did not delay the appearance of hepatic tumours nor prolong survival. In contrast, delayed HA FUdR infusion controlled hepatic metastases (P = 0.04) and improved survival (P < 0.05).     

Treatment outcomes for hepatocellular carcinoma using chemoembolization in combination with other therapies

BACKGROUND: Although transarterial chemoembolization (TACE) improves survival in patients with hepatocellular carcinoma (HCC), it is not known if TACE combined with other treatments is beneficial. Aim: To evaluate the evidence for improved outcomes in HCC with a multimodal treatment approach involving TACE. METHOD: PubMed search for all cohort and randomized trials (n=84) evaluating TACE combined with other therapies; meta-analysis performed where appropriate. RESULTS: A meta-analysis involving 4 RCTs showed a significant decrease in mortality favouring combination treatment (TACE plus percutaneous ablation) compared to monotherapy in patients with either small (<3cm) or large HCC nodules (>3cm) (OR, 0.534; 95% CI, 0.288-0.990; p=0.046). TACE combined with local radiotherapy improved survival in patients with tumour thrombosis of the portal vein in 7 non-randomized studies. Two RCTs and 13 non-randomized studies showed that TACE prior to hepatic resection does not improve survival nor tumour recurrence. Conversely, 2 RCTs and 5 comparative studies showed that transarterial injection of chemotherapeutic drugs mixed with lipiodol (TOCE) following hepatectomy confers survival benefit and less tumour recurrence. TACE before liver transplantation is safe and reduces drop-out rate from the waiting list, but there is no current evidence of improvement in subsequent survival or recurrence rate. CONCLUSIONS: A combined approach involving TACE and percutaneous ablation improves survival. Adjuvant TOCE improves outcome after hepatectomy. TACE is useful to control tumours burden while on the waiting list for OLT. Multimodal treatment seems to be the best way to optimize TACE outcomes in HCC.     

Resektion und Transplantation beim zentralen Gallengangskarzinom

Resection represents the only potential curative therapy option for central cholangiocarcinoma. Over the last 25 years, there has been an increase in radical surgery, however, without the formulation of a unified therapeutic concept. This development has peaked over the last few years, also in terms of long-term results. In 1999, we described the so called Berlin Concept as a combination of enlarged partial right-sided liver and portal vein resection. This leads to a survival rate over 5 years of 60%. In transplantation surgery, chiefly the Mayo Clinic group have shown a 5 year survival rate after neoadjuvant radiochemotherapy of 80% for selected patients, mainly those with a primary sklerosing cholangitis. Thus, central cholangiocarcinoma is today a tumor for which a better survival rate can be attained than a number of other gastrointestinal carcinomas.