Early liver cancer: concepts, diagnosis, and management

Hepatocellular carcinoma is a major health problem worldwide. The prognosis of patients depends on the stage when the disease is diagnosed. For the early detection of these tumors, both the selection of patients at high risk and effective surveillance programs are important. When the tumor is diagnosed early, patients can choose potentially curative treatment, including surgical resection, transplantation, and ablation therapy. Here, we give an overview of the present management of hepatocellular carcinoma. Further studies in diagnosis, treatment, and prevention are required to achieve the best clinical management of this disease.     

原发性阴道恶性黑色素瘤的研究进展

阴道恶性黑色素瘤是极其罕见的肿瘤,复发转移率高,治疗效果差,预后不良。目前有关治疗的最佳方案尚存在争议。本文通过复习原发性阴道恶性黑色素瘤的病例文献报道,并结合新的基础研究及临床试验,对该病的临床诊断、治疗方式和预后的研究进展进行综述。     

Breast cancer-related lymphedema: Symptoms,diagnosis, risk reduction,and management

The global burden of breast cancer continues to increase largely because of the aging and growth of the world population. More than 1.38 million women worldwide were estimated to be diagnosed with breast cancer in 2008, accounting for 23% of all diagnosed cancers in women. Given that the 5-year survival rate for breast cancer is now 90%, experiencing breast cancer is ultimately about quality of life. Women treated for breast cancer are facing a life-time risk of developing lymphedema, a chronic condition that occurs in up to 40% of this population and negatively affects breast cancer survivors’ quality of life. This review offers an insightful understanding of the condition by providing clinically relevant and evidence based knowledge regarding lymphedema symptoms, diagnosis, risk reduction, and management with the intent to inform health care professionals so that they might be better equipped to care for patients.     

Radiological diagnosis and management of proximal fallopian tube obstruction

Fluoroscopically guided transcervical fallopian tube catheterization is a valuable technique in the management of infertility, being applicable to occlusion of the proximal fallopian tube. It was first described in the literature in 1987. Our experience is discussed. Modifications to the usual technique are explained. The procedure has had a poor initial acceptance in Australia, but should replace tubal surgery or in vitro fertilization in a group of patients.     

食管癌及贲门癌术后隐匿胸腔瘘的诊断与治疗

目的 探讨食管癌及贲门癌术后隐匿胸腔瘘的诊断、治疗方法.方法 回顾性分析2010年1月至2013年9月40例行胸内胃食管吻合术的食管癌、贲门癌患者资料.40例患者出现高热、白细胞升高等脓毒血症表现,早期均无造影剂渗漏,但CT显示吻合口或胃残端周围出现散在小气泡、少量包裹性积液,存在吻合口或胃残端早期微小瘘口的可能,定义为隐匿胸腔瘘.20例按隐匿胸腔瘘处理,给予禁食、抗感染治疗、保持胃肠减压通畅、鼻肠管肠内营养等治疗;另20例按术后未出现胸腔瘘进行常规治疗,给予降温及抗生素治疗.比较两组胸腔瘘发生情况,总结泛影葡胺食管造影及胸部CT扫描隐匿胸腔瘘的特点.结果 按吻合口瘘处理的20例患者泛影葡胺食管造影及胸部CT扫描显示,有2例（10％）发展为较小的吻合口瘘,未按胸腔瘘处理的20例患者中有17例（85％）发展为胸腔瘘,6例并发多器官衰竭死亡.结论 食管癌、贲门癌术后出现脓毒血症表现,泛影葡胺食管造影及胸部CT扫描显示吻合口或胃残端周围有小气泡、不规则包裹性积液为隐匿胸腔瘘的特异性征象,应按胸腔瘘处理.     

骨髓增殖性疾病四例并文献复习

 目的　总结分析4例典型骨髓增殖性疾病（MPD）患者的诊治经过,并进行相关文献复习。方法　介绍1例真性红细胞增多症、2例原发性血小板增多症和1例原发性骨髓纤维化患者的诊治经过。结果　4例患者分别采用干扰素、干扰素联合羟基脲、同胞HLA相合异基因造血干细胞移植治疗,均获得满意疗效。结论　JAK2 V617F基因突变的检测使MPD的临床诊断变得更容易;真性红细胞增多症和原发性血小板增多症患者的治疗重点为预防并发症,而对于部分高危原发性骨髓纤维化患者应考虑异基因造血干细胞移植。     

Diagnosis and multi-disciplinary management of hepatic metastases from gastrointestinal stromal tumour (GIST)

Aim

To explore the present application of diagnosis and management of hepatic metastases from GIST.

Methods

We performed a systematic review of the literature for studies concerning hepatic metastases from GIST. A literature search was performed using the Medline/PubMed databases to identify publications relevant to the review published from January 1998 to December 2008. Totally 113 relevant articles were retrieved. Abstracts from recent ASCO symposia were hand searched for relevant articles. After the primary filtration, articles on review and with repetitive content were excluded. The articles on clinical research, which were issued in authorized journals, were selected. At last, totally 69 articles were included for review.

Findings

The rate of liver metastases was reported as 15.9% in primary GISTs. The recurrence rate following surgical resection for hepatic metastases from GIST had been reported as 70–77%. For metastatic GIST patients with tyrosine kinase inhibitor (TKI) treatment, it demonstrated rates of CR, PR and SD respectively of 5.84%, 50.7%, and 32.4%. Combining repeated surgery with TKI treatment, R0/R1 resection rates range in various series between 48 and 82%. For those patients with unresectable disease confined to the liver or unable to tolerate liver resection due to co-morbidity or advanced age, RFA, HACE, TKI therapy, or even liver transplantation, can also improve survival.

Conclusions

The liver is a common metastatic site for gastrointestinal stromal tumour (GIST). Appropriate initial evaluation remains paramount for selecting the correct management strategy. Multi-disciplinary management (which includes pathology, medical oncology, surgical oncology, and imaging expertise) of this disease is important for both curative and palliative treatment in these patients. Combining repeated surgery with TKI treatment may be the most effective management for GIST patients with liver metastases.     

局部复发鼻咽癌诊治研究进展

目前放射治疗虽仍为鼻咽癌首选治疗手段,且疗效令人满意,但仍有部分患者经积极治疗后难免出现鼻咽和／或颈部淋巴结复发,对这些患者有时诊断和治疗有一定困难。本文对近年来国内外文献进行归纳分析,介绍局部复发鼻咽癌的复发因素、临床特征、现代诊断技术以及现代放射治疗、化疗和手术治疗等挽救治疗的方法。     

Development of a model to predict permanent symptomatic postradiosurgery injury for arteriovenous malformation patients

Purpose: To better predict permanent complications from arteriovenous malformation (AVM) radiosurgery.

Methods and Materials: Data from 85 AVM patients who developed symptomatic complications following gamma knife radiosurgery and 337 control patients with no complications were evaluated as part of a multi-institutional study. Of the 85 patients with complications, 38 patients were classified as having permanent symptomatic sequelae (necrosis). AVM marginal doses varied from 10–35 Gy and treatment volumes from 0.26–47.9 cc. Median follow-up for patients without complications was 45 months (range: 24–92).

Results: Multivariate analysis of the effects of AVM location and the volume of tissue receiving 12 Gy or more (12-Gy-Volume) allowed construction of a significant postradiosurgery injury expression (SPIE) score. AVM locations in order of increasing risk and SPIE score (from 0–10) were: frontal, temporal, intraventricular, parietal, cerebellar, corpus callosum, occipital, medulla, thalamus, basal ganglia, and pons/midbrain. The final statistical model predicts risks of permanent symptomatic sequelae from SPIE scores and 12-Gy-Volumes. Prior hemorrhage, marginal dose, and Marginal-12-Gy-Volume (target volume excluded) did not significantly improve the risk-prediction model for permanent sequelae (p ≥ 0.39).

Conclusion: The risks of developing permanent symptomatic sequelae from AVM radiosurgery vary dramatically with location and, to a lesser extent, volume. These risks can be predicted according to the SPIE location-risk score and the 12-Gy-Volume.     

Assessment of neuropsychological changes in patients with arteriovenous malformation (AVM) after radiosurgery

Purpose: The purpose of this study was to investigate neuropsychological effects of radiosurgery in patients with cerebral arteriovenous malformation (AVM), with special focus on attention and memory. This report describes the study setup and presents the first results during a follow-up of up to 1 year.

Materials and Methods: Seventy-nine patients were studied before, acutely after radiosurgery, and during the regular follow-up (subacute phase: Weeks 6–12, chronic phase: Months 6–12). Radiosurgery was performed using a modified linear accelerator (minimum doses to the target volume: 15–22 Gy, median 20 Gy). Estimated whole brain dose was 0.5 to 2 Gy. Neuropsychological testing included assessment of general intelligence (Wechsler Adult Intelligence Scale), attention (modified Trail-Making Test A, Digit Symbol Test, D2 Test, Wiener Determination Machine) and memory (Rey Auditory Verbal Learning Test, Benton Visual Retention Test). During follow-up, alternate test versions were used. Neuropsychological deficits were defined as a test score of at least one standard deviation (SD) below the mean of the normal distribution.

Results: The pretherapeutic evaluation revealed marked deviations from the normal population; 24% had deficits in intelligence (range 23–31% in different subtests), attention (35%, 23–59%) and memory (48%, 31–61%). The overall percentage of aberrant results was reduced by 12% (memory) to 14% (attention) in the chronic phase up to 12 months after therapy. The improvement in test scores was significant (p < 0.05) in 3 of 4 subtests of attention functions.

Conclusions: The acute tolerance of radiosurgery seems to be very good in these patients, showing no relevant increase in number of patients with neuropsychological deficits. Although the long-term follow-up needs to be further increased, our data indicate a tendency to slight improvement in the overall neuropsychological performance of AVM patients in the chronic phase after radiosurgery.     

癌症患者谵妄的诊断和处理

谵妄是一种高级神经中枢急性活动失调状态，在癌症患者中，更多时候它是一个伴随症状，也可能是诊断和治疗的并发症。癌症患者尤其是终末期患者中，谵妄并不少见，但在国内至今没有受到重视。文章介绍了谵妄的临床表现、诊断及处理。     

Uterine arteriovenous malformation: A rare cause of uterine bleeding. Diagnosis and treatment

A case of uterine arteriovenous malformation following a dilatation and curettage is presented. Initial diagnosis with colour and pulsed Doppler ultrasound and treatment with transcatheter arterial embolization are described.     

45例胆囊癌的临床诊治分析

胆囊癌是胆道系统中常见的一种恶性肿瘤,男女发病率比例大约为1∶ 3[1],发病年龄大多为50岁以上.由于CT以及MRI等在临床上的广泛运用,明显提高了胆囊癌的早期诊断率,使胆囊癌的诊治也取得了一些进展.但是,胆囊癌仍是一种早期诊断困难、根治切除率低、预后差的恶性疾病,且近年来该病的发病率有逐渐增高的趋势,成为严重威胁人类健康的生命杀手.胆囊癌的预后主要取决于肿瘤所处的生长阶段.因此,如何提高胆囊癌的早期诊断率已成为目前治疗胆囊癌中一个急需解决的问题.我们收集了2004年3月至2010年6月间在我院肝胆外科采用手术治疗的45例胆囊癌患者的临床资料,并对其进行了回顾性分析,现将结果报告如下.     

Oropharyngeal mucositis in cancer therapy. Review of pathogenesis, diagnosis, and management

Oropharyngeal mucositis is a common and treatment-limiting side effect of cancer therapy. Severe oral mucositis can lead to the need to interrupt or discontinue cancer therapy and thus may have an impact on cure of the primary disease. Mucositis may also increase the risk of local and systemic infection and significantly affects quality of life and cost of care. Current care of patients with mucositis is essentially palliative and includes appropriate oral hygiene, nonirritating diet and oral care products, topical palliative mouth rinses, topical anesthetics, and opioid analgesics. Systemic analgesics are the mainstay of pain management. Topical approaches to pain management are under investigation. The literature supports use of benzydamine for prophylaxis of mucositis caused by conventional fractionationated head and neck radiotherapy, and cryotherapy for short-half-life stomatoxic chemotherapy, such as bolus fluorouracil. Continuing studies are investigating the potential use of biologic response modifiers and growth factors, including topical and systemic delivery of epithelial growth factors and agents. Progress in the prevention and management of mucositis will improve quality of life, reduce cost of care, and facilitate completion of more intensive cancer chemotherapy and radiotherapy protocols. In addition, improved management of mucositis may allow implementation of cancer treatment protocols that are currently excessively mucotoxic but may produce higher cure rates. Continuing research related to the pathogenesis and management of mucositis will undoubtedly lead to the development of potential interventions and improved patient care.     

规范和重视原发性骨髓纤维化的诊断和治疗

 近五年相继提出了原发性骨髓纤维化（PMF）的骨髓纤维化程度判断欧洲共识标准、国际预后积分系统（IPSS）和疗效标准，为PMF的规范化诊断和治疗奠定了基础。免疫调节剂如沙利度胺、雷利度胺和pomalidomide单独或联合小剂量泼尼松临床试验的完成，使得除造血干细胞移植以外的药物治疗逆转骨髓纤维化程度成为可能，新近JAK2抑制剂临床试验的开展使PMF进入分子靶向治疗新时代。文章结合国际上PMF研究的新认识，重点探讨了中国在该领域应引起重视的几个问题。     

上皮样肉瘤的病理诊断与鉴别诊断

目的探讨上皮样肉瘤的病理特点及鉴别诊断。方法13例上皮样肉瘤,男9例,女4例,年龄10～45岁。病变主要位于前臂、手掌和手指。行显微镜下观察组织形态特点并结合免疫组化染色结果进行分析。结果组织学表现为肿瘤细胞由恶性上皮样细胞和梭形细胞组成,呈结节样排列并伴有中心坏死。所有瘤组织CK、EMA和Vimentin均为阳性表达。结论上皮样肉瘤无特异性症状和体征,病理学特点及鉴别诊断应紧密结合临床表现和免疫组化结果。     

血清及胸腔积液中四种肿瘤标志物联合应用对良恶性肿瘤鉴别诊断价值的评估

目的探讨肿瘤标志物CEA、CA125、CA15-3及CA19-9联合应用对鉴别良性胸腔积液(BPE)和恶性胸腔积液(MPE)的价值。方法收集327例2013-01-01-2015-06-30在首都医科大学附属北京朝阳医院(174例)和华中科技大学同济医学院附属协和医院呼吸与危重症医学科(153例)住院的胸腔积液(PE)患者,其中MPE患者119例,BPE患者208例。取PE标本及配对血清标本,应用化学发光法检测CEA、CA125、CA15-3及CA19-9在血清及PE中的浓度,应用二元Logistic回归模型和L1正则化(LASSO)方法将患者基本信息与PE、血清中4种肿瘤标志物CEA、CA125、CA15-3及CA19-9进行不同方式的联合,通过受试者工作特征(ROC)曲线分析和比较不同联合诊断模型的诊断价值。结果PE中CEA+CA15-3+CA19-9的联合模型对应ROC曲线下面积(AUC)值最大(0.90),血清中此联合模型对应的AUC值也是最佳(0.863),PE中的联合模型优于血清中的联合诊断模型,P=0.0125,综合预测能力最强。PE与血清肿瘤标志物浓度差值中CEA+CA15-3+CA19-9的联合模型对应的灵敏度最佳(80.2%),特异度为79.1%。基于LASSO变量选择方法的联合模型在PE中的特异度最佳(96%),此时灵敏度为73%,阳性似然比22。以上结果均P<0.001。PE中CEA+CA15-3+CA19-9的联合模型对应的AUC值(0.90)优于PE中CEA对应的AUC值(0.824),P<0.001。结论联合应用CEA、CA15-3及CA19-9在诊断效能、灵敏度、特异度、阳性似然比等方面优于其他组合,且优于PE中的CEA对BPE/MPE的鉴别诊断价值。     

A short case of a splenic arteriovenous fistula coexisting with portal hypertension secondary to hepatitis C: Radiologic diagnosis and treatment

Splenic arteriovenous fistula (SAVF) is a rare but potentially curable condition. Only a few cases have been reported in the English literature. SAVF can cause portal hypertension, ascites, gastrointestinal bleeding, and heart failure. An early diagnosis is essential to avoid life threatening complications. We hereby present a case of SAVF in a young female patient, with hepatitis C liver cirrhosis who presented with recurrent severe upper gastrointestinal bleeding. Such an association of liver cirrhosis and SAVF has not been previously reported.