无水酒精注射联合射频消融治疗射频消融困难部位的肝癌

目的:探讨无水酒精注射联合射频消融治疗射频消融困难部位肝癌的疗效.方法:回顾性分析靠近结肠、胆囊、大中血管、膈肌等存在射频困难区肝癌患者31例,在采用射频治疗后残余病灶行无水酒精补充治疗,评价病灶坏死率及术后并发症.结果:31例患者的47个病灶当中共有33个病灶位于射频困难部位,肿瘤完全坏死率为72.7%(24/33).无腹腔内出血,胆囊穿孔,结肠穿孔等严重并发症出现.结论:射频困难部位的肝癌病灶采用射频补充无水酒精注射治疗效果良好,未见严重的射频或酒精注射相关并发症发生,可在肝癌的综合治疗中推广应用.     

无水酒精注射联合射频消融治疗射频消融困难部位的肝癌

目的：探讨无水酒精注射联合射频消融治疗射频消融困难部位肝癌的疗效。方法：回顾性分析靠近结肠、胆囊、大中血管、膈肌等存在射频困难区肝癌患者31例,在采用射频治疗后残余病灶行无水酒精补充治疗,评价病灶坏死率及术后并发症。结果：31例患者的47个病灶当中共有33个病灶位于射频困难部位,肿瘤完全坏死率为72.7%（24/33）。无腹腔内出血,胆囊穿孔,结肠穿孔等严重并发症出现。结论：射频困难部位的肝癌病灶采用射频补充无水酒精注射治疗效果良好,未见严重的射频或酒精注射相关并发症发生,可在肝癌的综合治疗中推广应用。     

肝动脉化疗栓塞术联合射频消融术治疗小肝癌的研究进展

原发性肝癌是世界性常见的恶性肿瘤之一,肝癌的早发现早治疗已成为临床研究的重点。射频消融术(RFA)在国内外已成为公认的对小肝癌治疗有效的一种手段,尤其对于直径小于3cm的小肝癌患者,治愈率已经达到甚至超过外科切除治疗。在治疗直径大于3cm的小肝癌患者,单一的RFA治疗复发率相对较高。肝动脉化疗栓塞(TACE)对小肝癌的治疗效果早已获得承认,但也存在一定的缺点。TACE术后改变了原有的动脉供血系统,侧支循环容易建立,病灶坏死率较低,复发率较高,多次TACE治疗会加重肝功能的损害。TACE与RAF联合能在小肝癌患者治疗中取长补短,提高治疗的安全性、有效性,以及对患者的远期疗效。本文主要对肝动脉化疗栓塞术联合射频消融术治疗小肝癌的现状及其进展做一综述。     

Multidisciplinary treatment of patients with hepatocellular carcinoma

Hepatocellular carcinoma is one of the most common malignancies in the world. When it is diagnosed, patients can choose from among several potentially curative treatments, such as surgical resection, transplantation, ablation therapy and transcatheter arterial chemoembolization. This review will give an overview of the present management of hepatocellular carcinoma. Liver transplantation is considered the best curative option, achieving a high rate of complete response, especially in patients with small hepatocellular carcinoma and good residual liver function. However, a shortage of donor livers restricts the availability of transplantation. In addition, only a minority of patients with hepatocellular carcinoma can be treated surgically, owing to impaired hepatic reserve, multiple intrahepatic lesions, extrahepatic lesions and the inability to obtain an optimal tumor-free margin. Therefore, for most patients, other types of interventions (transcatheter arterial chemoembolization, percutaneous ethanol injection and radiofrequency ablation) have been developed. Among them, two local ablative modalities, percutaneous ethanol injection and percutaneous radiofrequency ablation, have been accepted as the only potentially curative nonsurgical treatments for hepatocellular carcinoma. Radiofrequency ablation may become a standard nonsurgical treatment option for patients with early hepatocellular carcinoma.     

腹腔镜肝切除在复发性肝癌治疗中的应用

目的:探讨复发性肝癌行腹腔镜再切除的可行性和适应证.方法:回顾性分析我科2014年1月至2015年11月期间收治的11例复发肝癌患者行腹腔镜再切除的临床资料,其中复发肿瘤位于同侧者5例,位于对侧者6例.结果:所有患者均顺利完成手术,其中9例完全腹腔镜下手术,2例中转开腹,中转开腹者均为同侧复发组病例,所有患者术后无严重并发症发生.其中行腹腔镜手术患者手术时间(145.0±30.9)min,术中失血量(150.0±45.5)ml,住院天数(6.8±2.2)天.结论:在严格把握手术适应证的前提下,复发性肝癌行腹腔镜再切除是安全、可行的.     

晚期肝癌低频超声空化治疗的超声血管造影表现

目的观察晚期肝癌患者低频超声空化治疗的超声血管造影表现。方法晚期肝癌患者12例(其中原发性肝癌7例,转移性肝癌5例),行低频超声空化治疗。治疗前、后进行超声微血管造影。结果通过超声血管造影能够清晰地看到肿瘤微血管。低频超声空化治疗后肿瘤血管造影强度低于治疗前,且治疗后病灶内出现低回声区。结论低频超声空化治疗具有毁损肿瘤血管的作用;超声微血管造影可以用来评估低频超声空化治疗后肿瘤血管的破坏情况。     

Ⅲ期或Ⅳa1期肝癌肝移植的生活质量和生存率

目的 评价中期原发性肝癌(简称肝癌)肝移植的治疗效果,探讨更适合我国国情的肝癌肝移植标准.方法 以美国肝癌研究小组改良的TNM分期为基础,将肝癌分为早(Ⅰ期或Ⅱ期)、中(Ⅲ期或Ⅳa1期)、晚(Ⅳa2期或Ⅳb期)三期.用卡氏体能状况评分系统(Karnofsky performance status,KPS)作为生活质量评价工具,对我院2003年3月至2006年1月实施的中期肝癌肝移植分别于术前和术后评价其生活质量,记录术后无瘤存活时间和总存活时间,并计算不同时间点的无瘤生存率和总生存率.结果 中期肝癌患者术前生活质量属"低下"范畴,肝移植手术1周后生活质量逐步改善,3周时即显著优于术前(P=0.038),3个月和6个月时均有进一步改善.9个月时无瘤者生活质量即达到"良好"水平,与健康人相当,并在观察期结束时保持在这一高水平状态.术后1年、2年和3年生存率分别为91.0%、83.2%和80.0%,无瘤生存率分别为86.5%、81.9%和79.4%.结论 中期肝癌患者接受肝移植治疗能改善生活质量、延长生存时间,对中期肝癌可积极考虑肝移植治疗.     

青年原发性肝癌临床特点分析

目的探讨青年原发性肝癌的临床特点.方法分析86例青年肝癌患者(年龄＜40岁)的临床特点,包括临床症状体征、肝癌家族史、饮酒史、HBV感染率、HCV感染率、ALT异常、AFP阳性、AFU阳性、合并肝硬化、门静脉癌栓以及肝癌类型,并与同期122例老年肝癌患者(年龄＞60岁)进行比较.结果青年肝癌患者占原发性肝癌患者的13.6%,在以下方面比例高于老年组,且有显著性或极其显著性差异:发热(36.0%)、HBV感染(86.0%)、ALT异常(74.4%)、AFP阳性(76.7%)、AFU阳性(81.4%)、门静脉癌栓(29.1%)和弥漫性肝癌(33.7%).结论青年肝癌恶性程度高,对HHBV感染ALT反复异常的青年人要定期进行B超和AFP检查,以便早期发现、早期治疗原发性肝癌.     

干扰素辅助治疗肝癌随机对照试验的Meta分析

目的:用Meta分析的方法定量评价干扰素辅助治疗肝癌的效果。方法:计算机检索EMbase、PubMed、Cochrane图书馆、中国生物医学文献数据库、中国期刊全文数据库(CNKI)、维普中文科技期刊数据库,收集有关干扰素辅助治疗肝癌的随机对照试验(randomized controlled trial,RCT),两名评价者单独评价纳入研究的方法学质量并提取资料,用Cochrane协作网提供的RevMan5.0软件进行Meta分析。结果:共纳入8篇RCTs,共计836例患者。Meta分析结果显示,肝癌患者接受基础治疗后,干扰素辅助治疗组在复发率方面与安慰剂组相比,差异有统计学意义[RR=0.86,95%CI(0.77,0.96),P<0.05];两组在病死率方面的差异也有统计学意义[RR=0.64,95%CI(0.54,0.76),P<0.05]。结论:干扰素辅助治疗可以降低肝癌患者的病死率和复发率,但远期疗效尚待大样本、高质量的RCTs进一步证实。     

Significance of reduction surgery in multidisciplinary treatment of advanced hepatocellular carcinoma with multiple intrahepatic lesions

BACKGROUND AND OBJECTIVES: By comparing the survival rates of patients treated with or without surgery, the significance of, and the indication for, reduction surgery in the multidisciplinary treatment of patients with HCC with multiple intrahepatic lesions were examined. METHODS: In patients with HCC with multiple intrahepatic lesions, cumulative survival rates were determined and compared for 28 patients (group S) who underwent reductive hepatic resection and 43 (group N) who were treated nonsurgically by transcatheter arterial infusion chemotherapy (TAI), transcatheter arterial chemoembolization (TACE), or percutaneous transhepatic ethanol injection therapy. In group S, 20 patients had adjuvant therapy, consisting of ethanol injection therapy or microwave coagulonecrotic therapy for the remaining satellite lesions during hepatectomy, and all patients in this group underwent TAI or TACE postoperatively. The influence of surgery on patient survival was examined by multiple regression analysis using the Cox's hazard model; then, for each prognostic factor, survival rates were obtained and compared between the groups. RESULTS: In group S, the 1-, 3-, and 5-year cumulative survival rates were 58.2%, 27.1%, and 21.7%, whereas the corresponding values in group N were 34.3%, 4.7%, and 4.7%, the difference being statistically significant (P = 0.0239). In group S, the 1-, 3-, and 5-year cumulative survival rates for patients without intraoperative adjuvant therapy were 25%, 0%, and 0%, whereas those for patients with intraoperative adjuvant therapy were 72.7%, 41.3%, and 33.0% (P = 0.001). Multiple regression analysis showed that hepatic resection, the Child-Pugh score, and the size of the main tumor affected survival independently. Univariate analysis of differences in the cumulative survival rates between the groups as a function of prognostic factor showed that group S had statistically significant better survival rates than group N in those subgroups of patients who were <60 years old, with HBV infection, with a Child-Pugh score of 5 or 6, with a main tumor of <5-cm diameter, with <5 tumors, or without portal thrombi. CONCLUSIONS: When combined with intraoperative adjuvant therapy for remaining satellite tumors, reduction surgery provided survival benefit for patients with HCC with multiple intrahepatic lesions in those groups of patients selected by criteria determined in this study.     

Radiofrequency ablation or microwave ablation combined with transcatheter arterial chemoembolization in treatment of hepatocellular carcinoma by comparing with radiofrequency ablation alone简

Objective：To compare radiofrequency ablation （RFA） or microwave ablation （MWA） and transcatheter arterial chemoembolization （TACE） with RFA or MWA monotherapy in hepatocellular carcinoma （HCC）.Methods：A prospective,randomized,controlled trial was conducted on 94 patients with HCC ≤7 cm at a single tertiary referral center from June 2008 to June 2010 at the Department of Hepatobiliary Surgery,the Second Affiliated Hospital of Southeast University.The patients were randomly assigned into the TACERFA or TACE-MWA （combined treatment group） and the RFA-alone or MWA-alone groups （control group）.The primary end point was overall survival.The secondary end point was recurrence-free survival,and the tertiary end point was adverse effects.Results：Until the time of censor,17 patients in the TACE-RFA or TACE-MWA group had died.The median follow-up time of the patients who were still alive for the TACE-RFA or TACE-MWA group was 47.5±11.3 months （range,29 to 62 months）.The 1-,3-and 5-year overall survival for the TACE-RFA or TACE-MWA group was 93.6％,68.1％ and 61.7％,respectively.Twenty-five patients in the RFA or MWA group had died.The median follow-up time of the patients who were still alive for the RFA or MWA group was 47.0±12.9 months （range,28 to 62 months）.The 1-,3-and 5-year overall survival for the RFA or MWA group was 85.1％,59.6％ and 44.7％,respectively.The patients in the TACE-RFA or TACE-MWA group had better overall survival than the RFA or MWA group [hazard ratio （HR）,0.526; 95％ confidence interval （95％ CO,0.334-0.823; P=0.002],and showed better recurrence-free survival than the RFA or MWA group （HR,0.582; 95％ CI,0.368-0.895; P=0.008）.Conclusions：RFA or MWA combined with TACE in the treatment of HCC ≤7 cm was superior to RFA or MWA alone in improving survival by reducing arterial and portal blood flow due to TACE with iodized oil before RFA.     

Fractionated stereotactic radiotherapy in patients with primary hepatocellular carcinoma

OBJECTIVE: The purpose of our study was to evaluate the feasibility and treatment outcomes of fractionated stereotactic radiotherapy (SRT) for primary hepatocellular carcinoma (HCC). METHODS: We enrolled 20 patients who had been histologically diagnosed as HCC patients and treated by fractionated SRT. Tumor size was 2-6.5 cm (average: 3.8 cm). We prescribed 50 Gy in 5 or 10 fractions at the 85-90% isodose line of the planning target volume for 2 weeks. The follow-up period was 3-55 months (median: 23 months). RESULTS: The overall response rate was 80%, with 4 patients showing complete response (20%), 14 patients showing partial response (60%) and 4 patients showing stable disease (20%). The 1-year and 2-year survival rates were 70.0 and 43.1%, respectively (median: 20 months). The 1-year and 2-year disease-free survival rates were 65.0 and 32.5%, respectively (median: 19 months). The fractionated SRT was well tolerated, because grade 3 or grade 4 toxicity was not observed. CONCLUSION: These results suggest that fractionated SRT is a relatively safe and effective method for treating small primary HCC. Thus, fractionated SRT may be suggested as a local treatment of choice for small HCC when the patients are inoperable or when the patients refuse operation.     

肝癌自发破裂出血诊治体会（附29例报告）

目的：探讨肝癌自发破裂出血的诊治方法。方法：回顾性分析我院1995年1月-2007年5月间收治的29例肝癌自发破裂出血患者的临床资料。开腹手术16例，其中行肝脏部分切除10例，单纯缝扎3例，局部填塞2例，缝扎加肝动脉结扎1例。介入治疗9例，其中3例术后再行开腹手术治疗。保守治疗4例。结果：死亡5例，其中开腹手术1例，介入治疗1例，保守治疗3例。开腹手术患者1年生存率43．8％（7／16），介入治疗33．3％（3／9），保守治疗0．0％（0／4）。结论：积极手术及介入治疗可增加抢救成功机会，合理选择治疗方案是提高远期疗效的关键。     

Fibrolamellar hepatocellular carcinoma in Mexican patients

The aim of this report is to describe the frequency, clinical, and morphologic characteristics of fibrolamellar hepatocellular carcinoma in Mexican patients. Fibrolamellar hepatocellular carcinoma (FLHCC) is a rare variant of hepatocellular carcinoma. Although this tumor appears to be predominant among the Caucasian population of the U.S, FLHCC has been described in many other countries. The frequency and characteristics of FLHCC in Latin American population is almost unknown. The clinico-pathologic characteristics of seven (5.8%) Mexican patients with FLHCC, obtained among 121 hepato-cellular carcinomas are described. The frequency of these tumors was compared with the frequency reported in other geographic areas in the international literature between 1980 and 1999. There were four women and three men. Two patients had taken oral contraceptives for six months and a year prior to diagnosis; another patient had positive serology for the hepatitis B virus. Common symptoms included a palpable mass, abdominal pain and weight loss; two patients presented jaundice. In two patients the tumor had been removed eight and three years previously, and they were readmitted when FLHCC recurred. In three patients the diagnosis was suspected in radiological studies (computed tomography and/or magnetic resonance). Laboratory tests were non-specific. In four patients, resection of the tumor was performed, and in the remaining three the neoplasm was diagnosed by percutaneous hepatic biopsy. Two patients had died of disease at the time of the study, and another was alive with recurrent disease. Conclusions: fibrolamellar hepatocarcinoma is an uncommon, but not an exceptional neoplasm in our population and represents 5.8% of all hepatocarcinomas reviewed.     

Excellent outcomes with angiographic subsegmentectomy in the treatment of typical hepatocellular carcinoma

BACKGROUND:

The authors successfully adopted an interesting and effective treatment for hepatocellular carcinoma (HCC) referred to as angiographic subsegmentectomy (AS). This treatment involved simultaneous embolization of the peripheral feeding artery and the portal vein. The result was that almost all of the HCC and peripheral liver parenchyma developed complete anatomic necrosis.

METHODS:

To determine the effectiveness of this method, the authors retrospectively studied the local recurrence rates of 49 solitary HCCs and the long‐term survival rates of 120 patients with HCC between 2000 and 2008.

RESULTS:

The results indicated that, in 31 small, solitary HCCs (<2.0 cm), the local recurrence rate was only 9.6%; and, in 10 slightly larger HCCs (<3.0 cm), the local recurrence rate was only 10%. The 5‐year, 8‐year, and 10‐year survival rates for patients with stage I and stage I/Child‐Pugh grade A HCC were 74.27% and 77.65%, 53.05% and 51.76%, and 53% and 51.76%, respectively; and the 5‐year, 8‐year, and 10‐year survival rates for patients with stage II and stage II/Child‐Pugh grade A HCC were 66.21% and 71.41%, 39.9% and 39.60%, and 29.92% and 25%), respectively. There were no severe complications.

CONCLUSIONS:

AS should be investigated further as potential first‐line therapy for the treatment of patients with stage I and II HCC. Cancer 2010. © 2010 American Cancer Society.     

以外科手术为主综合治疗小肝癌134例临床报告

背景与目的：手术切除是治疗小肝癌的首选方法,但术后5年复发率高达35．4％－45．3％,是影响手术疗效的关键因素。本研究拟探讨以外科为主的综合治疗来降低小肝癌术后复发率。方法：以外科为主综合治疗小肝癌（直径≤5cm）患者134例,男119例,女15例,年龄18－70岁,中位年龄45岁;手术切除（切除组）121例,其中,不规则性肝叶切除16例,局部切除83例,肝叶或肝段切除12例,左半肝切除2例,联合胆吓切除8例;切除后切缘注射无水酒精或用渗入无水酒精的明胶海绵包埋于瘤床共22例。手术不能切除13例,行肝固有动脉结扎合并肝动脉及门静脉双插管化疗或瘤体内注射无水酒精或冷冻、射频治疗、微波固化、栓塞化疗等。结果：小肝癌手术切除率90．3％,无手术死亡。切除组术后1、3、5、10年生存率分别为89．3％、74．4％、64．6％和43．8％;术后1、3、5年复发率分别为11．9％、23．8％和32．1％。全组1、3、5、10年生存率分别为88．8％、72．2％、63．4％和41．7％;1、3、5年复发率分别为15．9％、29．1％和36．6％。结论：手术切除是治疗小肝癌的有效方法,以个体化为原则外科为主的综合治疗可降低术后复发率,提高小肝癌治疗效果。     

Thermal ablation of hepatocellular carcinoma in patients with abnormal coagulation function

Objective: To evaluate the safety of thermal ablation for hepatocellular carcinoma (HCC) in patients with abnormal coagulation function.

Methods: Fifty-seven HCC tumours in 50 patients were treated with thermal ablation. All patients had a meted platelet count?<50?×?10⁹/L or international normalised ratio (INR)?≥?1.7. Gastroscopy before ablation, platelet concentrate or fresh frozen plasma transfusion during ablation and contrast enhanced ultrasoundgraphy (CEUS)-guided ablation to cease needle tract bleeding were performed to reduce haemorrhage. The incidences of haemorrhage and other major complications were recorded and patients were followed up to observe the local tumour progression (LTP), intrahepatic distant recurrence (IDR), overall survival (OS) and recurrence-free survival (RFS) rates.

Results: Two incidences of needle tract bleeding and one needle tract bleeding together with bleeding at the suture of the spleen fossa were found. Three needle tract bleeding events were detected by CEUS and ceased after CEUS-guided complementary ablation. CEUS failed to detect bleeding at the suture of the spleen fossa. Therefore, a laparotomy was conducted for haemostasis. No other major complications were found after ablation. The median follow-up periods were 18.7?±?12.0?months (range 1?～?42?months) and 1 LTP and 15 IDRs occurred. The 1-, 2- and 3-year OS rates were 84.8%, 82.7% and 82.7%, and RFS rates were 67.9%, 64.0% and 64.0%, respectively.

Conclusion: With gastroscopy before ablation, platelet concentrate or fresh frozen plasma transfusion during ablation and CEUS-guided ablation to cease needle tract bleeding, thermal ablation is a safe treatment for HCC in patients with abnormal coagulation function.