大剂量分割三维适形放疗对原发性肝癌门静脉癌栓的疗效

目的观察大剂量分割三维适形放疗（3-dimensional conformal radiotherapy,3DCRT）对不能手术切除的原发性肝癌（hepatocellular carcinoma,HCC）门静脉癌栓（portal vein tumor thrombus,PVTT）的疗效。方法对56例不能手术切除的HCC伴PVTT患者,根据肿瘤体积大小行大剂量分割3DCRT,放疗剂量为4～8Gy,每周3次,48～58Gy,3.0～3.5周完成。大体肿瘤靶区（GTV）包括癌栓及靠近的原发灶,90%等剂量曲线覆盖计划靶区（PTV）。结果有效率（CR＋PR）为58.9%（33/56）,1、2年生存率分别为47.4%和17.5%。患者耐受性好,无严重放疗并发症。结论大剂量分割3DCRT对HCC合并PVTT有较好的疗效。     

Sorafenib With and Without Transarterial Chemoembolization for Advanced Hepatocellular Carcinoma With Main Portal Vein Tumor Thrombosis: A Retrospective Analysis

Background.

The survival benefit of combining sorafenib and transarterial chemoembolization (TACE) therapy compared with sorafenib monotherapy for patients with advanced hepatocellular carcinoma (HCC) and main portal vein tumor thrombosis (MPVTT) is unclear.

Methods.

Between January 2009 and June 2013, 183 consecutive patients with advanced HCC (Barcelona Clinic Liver Cancer stage C) and MPVTT were retrospectively reviewed. Of these, 89 patients with advanced HCC and MPVTT were enrolled in this study: 45 were treated with combination therapy (sorafenib-TACE group), and the other 44 treated with sorafenib monotherapy (sorafenib group).

Results.

The mean number of TACE sessions per patient was 2.6 (range: 1–5). The median duration of sorafenib in the sorafenib-TACE group and sorafenib group was 5.6 months and 5.4 months, respectively. The disease control rate was similar between the two groups. Median time to progression was 3.0 months (95% confidence interval [CI]: 2.2, 3.7) in the sorafenib-TACE group, and 3.0 months (95% CI: 2.1, 3.8) in the sorafenib group (p = .924). Median overall survival was 7.0 months (95% CI: 6.1, 7.8) and 6.0 months (95% CI: 4.7, 7.3) in the sorafenib-TACE group and the sorafenib group, respectively (p = .544). The adverse events related to sorafenib were comparable between the two groups. Twenty-one adverse events of grade 3–4 related to TACE occurred in 12 patients (26.7%), and 2 of them died (4.4%).

Conclusion.

This study demonstrated no advantage of combination therapy over sorafenib monotherapy. Considering the patients’ morbidity after TACE, sorafenib monotherapy is appropriate for managing patients with advanced HCC and MPVTT.

Implications for Practice:

For patients with advanced hepatocellular carcinoma (HCC) and main portal vein tumor thrombosis (MPVTT), no benefit was seen in this study in terms of disease control rate, time to progression, and overall survival for patients receiving sorafenib and transarterial chemoembolization compared with those receiving sorafenib monotherapy. Considering the patients’ morbidity after combination therapy, monotherapy is appropriate for managing patients with advanced HCC and MPVTT.     

肾癌下腔静脉癌栓的诊断及治疗(附6例报告并文献复习)

提高对肾癌下腔静脉癌栓的认识。方法：结合文献复习对６例下腔静脉癌栓的诊断及治疗,进行讨。结果：６例经磁共振成像均确定癌栓范围,其中４例膈下型,２例为膈上。全部手术取出癌栓,１例术后１２天死于急性肾功能衰竭,１例术后１６个月死于肝转移,其余４例目前健在,最长者已生存４３个月。     

局部化疗和内支架植入对肝癌并下腔静脉梗阻患者治疗作用的评价

目的:评估肝癌并下腔静脉梗阻患者肝动脉局部化疗和下腔静脉内支架植入的治疗效果。方法:回顾性分析肝癌并下腔静脉梗阻患者29例,18例行肝动脉灌注化疗药物或结合碘油栓塞(局部化疗组),11例除上述治疗外,还行下腔静脉支架植入(支架植入组),观察两组症状改善及随访生存期。结果:局部化疗组18例,术后1周下腔静脉梗阻症状无明显改善,部分病例甚至有所加重。6～10周内4例患者死亡,余14例中5例下腔静脉梗阻症状减轻。支架植入组11例中,9例支架植入后1周内下腔静脉梗阻症状消失,2例减轻,6～10周内无1例患者死亡,下腔静脉梗阻症状消失达10例。随访生存期,局部化疗组3.5±4.2个月,支架植入组8.3±5.9个月,差异有显著性(P<0.01)。结论:1)对伴有下腔静脉梗阻的中晚期肝癌,单纯灌注化疗药物作用甚微,肝动脉灌注化疗药物结合栓塞术可能部分改善下腔静脉梗阻症状;2)内支架植入能即刻改善下腔静脉梗阻症状,与局部化疗相结合,中期疗效确定,生存期延长。     

下腔静脉平滑肌肉瘤的诊治

目的：了解下腔静脉平滑肌肉瘤的临床特点，提高对下腔静脉平滑肌肉瘤的诊治能力，探讨其合理的治疗方法。方法：对近10年收治的7例下腔静脉平滑肌肉瘤患者的临床资料进行回顾性分析。结果：7例患者均实施手术及经病理证实，6例行肿瘤及相应的下腔静脉切除和必要的下腔静脉重建，1例仅行剖腹探查。结论：肿瘤整块切除及必要的下腔静脉重建是治疗下腔静脉平滑肌肉瘤唯一有效的方法。     

大分割三维适形放疗联合化疗治疗中晚期肝癌45例疗效分析

 目的 探讨大分割三维适形放射治疗联合化疗治疗中晚期肝癌的疗效。 方法 对45例不能手术的中晚期肝癌患者进行介入治疗两次, 其中22例结合大分割三维适形放射治疗, 采用6MV X线, 单剂量为3~5Gy, 隔日1次,总剂量为DT 45～55Gy 23例单纯介入治疗。 结果 大分割三维适形放疗联合介入治疗组近期有效率(CR+PR)为85.7%,对照组为52.3%,两组差异有统计学意义;1、2、3年的生存率联合治疗组为68.7%,56.8%, 39.8%,对照组为51.2%, 28.7%, 15.7%,两者差异有统计学意义。两组间不良反应差异无统计学意义(P>0.05）。 结论 对于不能手术切除的中晚期肝癌患者, 大分割3DCRT结合TACE有较好的疗效,不良反应可以耐受。     

Hepatic Resection after Initial Transarterial Chemoembolization Versus Transarterial Chemoembolization Alone for the Treatment of Hepatocellular Carcinoma: A Meta-analysis of Observational Studies

Background: There is no consensus regarding the selection of treatment options for hepatocellular carcinoma (HCC) after initial transarterial chemoembolization (TACE). This meta-analysis aimed to explore the survival benefit of hepatic resection after initial TACE for the treatment of HCC. Materials and Methods: We searched three major databases to identify all relevant papers comparing the outcomes of hepatic resection after initial TACE versus TACE alone for the treatment of HCC. Hazard ratios (HRs) with 95% confidence intervals (95%CIs) were calculated to evaluate the survival benefit of hepatic resection after initial TACE over TACE alone. Results: Three of 2037 initially identified papers were included. All of them were cohort studies from Asia. There was a significantly better overall survival (OS) in patients undergoing hepatic resection after initial TACE than in those undergoing TACE alone (HR=0.63, 95%CI=0.52-0.76, P<0.00001). The heterogeneity among studies was not statistically significant (P=0.96; I2=0%). Conclusions: Hepatic resection could improve the OS of HCC patients treated with initial TACE. Further randomized controlled trials should be necessary to identify the target population for the sequential use of hepatic resection after initial TACE and to compare the outcomes between patients undergoing hepatic resection after initial TACE session versus those undergoing TACE alone.     

Neoadjuvant Sunitinib Decreases Inferior Vena Caval Thrombus Size and Is Associated With Improved Oncologic Outcomes: A Multicenter Comparative Analysis

BackgroundWe analyzed outcomes of neoadjuvant sunitinib in patients with renal-cell carcinoma (RCC) and inferior vena caval (IVC) tumor and compared outcomes to patients who did not undergo neoadjuvant therapy before surgery.Patients and MethodsWe performed a multicenter retrospective comparison of RCC patients with IVC tumor who underwent neoadjuvant sunitinib before surgery versus those who did not. Response to sunitinib was defined by Response Evaluation Criteria in Solid Tumors (RECIST). Primary outcome was cancer-specific survival. Secondary outcomes included overall survival. Multivariate analysis was performed to identify risk factors associated with primary and secondary outcomes. Kaplan-Meier analysis compared survival in neoadjuvant and primary surgery groups.ResultsData of 53 patients were analyzed (19 neoadjuvant sunitinib, 34 primary surgery; median follow-up, 58 months). Eighteen (9 in each group, P = .143) had metastatic RCC. There was no difference in IVC tumor level between the 2 groups (P = .76). After neoadjuvant sunitinib, median primary tumor decreased size from 8.1 to 6.8 cm, and IVC tumor decreased by 1.3 cm. IVC tumor level decreased in 8 (42.1%) of 19 and was stable in 10 (52.6%) of 19; 5 (26.3%) of 19 experienced partial response. Similar proportions of patients underwent robot-assisted or minimally invasive approaches (P = .351), and no differences were noted in complications (P = .194). Multivariate analysis showed neoadjuvant sunitinib was associated with improved cancer-specific survival (odds ratio = 3.28; P = .021). Kaplan-Meier analysis demonstrated significantly longer median cancer-specific survival (72 vs. 38 months, P = .023) for neoadjuvant sunitinib.ConclusionNeoadjuvant sunitinib was associated with a reduction in primary tumor and thrombus size as well as improved survival. Further investigation is needed to determine the utility of neoadjuvant sunitinib in RCC with IVC tumor.     

Efficacy of Transarterial Chemoembolization Combined with Radiofrequency Ablation in Treatment of Hepatocellular Carcinoma

Purpose: To evaluate efficacy of transarterial chemoembolization (TACE) combined with radiofrequencyablation (RFA) in treatment of patients with hepatocellular carcinoma. Materials and Methods: During January2009 to March 2012, 80 patients with hepatocellular carcinoma underwent TACE, with or without RFA. Alfafetoprotein(AFP) was checked before and after procedure. CT scans were obtained one month after TACE or RFAfor all patients to evaluate tumor changes. Complete response+partial response+stable disease (CR+PR+SD)/nwere used to assess the disease control rate (DCR). Survival at 3, 6 and 12 months was compared in both groups.Results: AFP levels in TACE + RFA group dropped rapidly, becoming obviously lower than that of the TACEgroup. In the TACE + RFA group DCR was 93.8%, while only 76.8% in the TACE group. The treatment effectbetween the two groups was statistically significant (P<0.05) by Ridit analysis. 1 year survival rate in the TACE+ RFA group was 92.5%, significantly higher than that of the TACE group at 77.5% (P<0.05). Conclusions:TACE and RFA as combined therapy method for patients with middle and terminal stage HCC gives full playto synergy between the two and improves the therapeutic effect.     

TACE联合冷循环PMCT治疗原发性肝癌的临床应用

目的：评价肝动脉化疗栓塞（TACE）联合冷循环经皮微波凝固治疗（PMCT）原发性肝癌的临床疗效。方法：71例确诊为原发性肝癌的患者,分期是Ⅰa～Ⅲa,随机分为治疗组（PMCT和TACE联合治疗组）33例,对照组（TACE组）38例。治疗组患者先行TACE治疗,2～4周后根据复查的AFP和CT/MR等的影像学检查决定再次行TACE或者PMCT。随访时间5～48个月（平均25.5个月）,随访内容包括AFP、肝功能、影像学资料、并发症等。根据随访的生存时间、复发情况作统计学分析。结果：治疗组和对照组治疗的肝癌患者的1、2、3年累积生存率分别是84.23%、72.29%、61.96%和55.84%、22.79%、11.40%,治疗组和对照组治疗的肝癌患者的6个月、12个月、24个月累积复发率分别6.06%、9.09%、24.24%和7.89%、31.57%、60.52%。TACE联合PMCT治疗肝癌没有严重并发症,对肝功能的损害轻。治疗组33例有5例合并动静脉瘘（AVF）,经动脉栓塞治疗后2例AVF消失,3例治疗后效果不理想的患者行PMCT后AVF消失。结论：本组研究初步显示,TACE联合PMCT治疗原发性肝癌是安全、有效、可行的方法,在治疗原发性肝癌的临床应用近、中期的效果好。PMCT提供了治疗肝癌合并AVF新的方法。     

The Impact of Sorafenib in Combination with Transarterial Chemoembolization on the Outcomes of Intermediate-Stage Hepatocellular Carcinoma

Background: We investigated the treatment outcomes and hepatic reserve of transarterial chemoembolization (TACE)-refractory patients with recurrent advanced hepatocellular carcinoma (HCC) treated with TACE plus sorafenib. Methods: Forty-one patients with intermediate-stage HCC defined as being TACE refractory on imaging were treated with sorafenib and TACE between 2009 and 2012 and comprised the combination treatment group. Twenty-nine patients who received repeated TACE after becoming refractory to TACE between 2005 and 2008 comprised the TACE continuation group. Results: Although the interval between successive rounds of TACE was significantly shorter before the patients developed TACE refractoriness, it was significantly longer after the development of TACE refractoriness, in the combination treatment group compared with the TACE continuation group. The appearance of extrahepatic spread and/or vascular invasion differed significantly between the two groups. The median overall survival was significantly longer in the combination treatment group than in the TACE continuation group (20.5 vs. 15.4 months, respectively; hazard ratio = 2.04; 95% confidence interval = 1.20–3.48). The 3-year overall survival rate was 33.4% in the combination treatment group and 3.5% in the TACE continuation group. Downstaging of the Child–Pugh class was significantly less frequent in the combination treatment group than in the TACE continuation group. In COX proportional hazards analyses, sorafenib plus TACE resulted in a better prognosis compared with repeated TACE. Conclusions: Treatment with sorafenib plus TACE in TACE-refractory patients with intermediate-stage HCC resulted in longer intervals between TACE rounds, better maintenance of hepatic reserve, and significantly longer OS compared with repeated TACE.     

8cm以上肝癌术后残癌的肝动脉栓塞化疗预后因素分析

目的：了解肝动脉栓塞化疗对直径大于8cm肝癌术后残癌的疗效和影响预后的因素。方法：肝癌切除术后2个月内经超声和动脉造影证实有残癌的肝癌患者，行肝动脉栓塞化疗；采用COX模型研究影响疗效的因素。结果：治疗后1，2，3，4年生存率为74.9%，44.2%，36.8%，18.4%。肝癌切除术后残癌的TNM分期是影响疗效的独立因素（P=0.003)。而原发癌的肿瘤分期，手术方式（局部切除或肝叶切除），肝动脉栓塞化疗的次数，不是影响预后的独立因素。结论：肝癌术后行肝动脉栓塞化疗是可行的，术后残癌的分期是影响肝动脉栓塞化疗效果的主要因素，大体积肿瘤术后尽早行肝动脉栓塞化疗是必要的。     

金米冲剂联合化疗栓塞治疗原发性肝癌的疗效观察

目的观察金米冲剂(Star-1)联合化疗栓塞(TACE)治疗原发性肝癌的疗效,及对血清血管内皮生长因子(VEGF)表达的影响。方法将60例原发性肝癌患者随机分为金米冲剂加TACE组与单纯TACE组,所有病例于TACE术前、术后7天及1个月时分别采集空腹血,应用ELISA法测定血清中VEGF表达水平。结果金米冲剂加TACE组术后第7天血清VEGF水平较术前无明显升高(P>0.05),术后1个月血清VEGF水平较术前略有下降(P>0.05)。而单纯TACE组术后第7天血清VEGF水平较术前明显升高,差异有统计学意义(P<0.05),术后1个月血清VEGF水平逐渐下降,与术前相比,差异无明显统计学意义(P>0.05)。结论金米冲剂可降低原发性肝癌患者血清中VEGF的表达水平,提示金米冲剂对肝癌的肿瘤血管生成具有一定地抑制作用。     

原发性肝癌合并门静脉癌栓的介入治疗进展

门静脉癌栓是导致肝癌远处转移及术后复发的重要因素之一，严重影响肝癌患者预后。针对门静脉癌栓，目前仍缺乏有效手段，介入治疗以其微创、可重复性等优点存临床得到广泛应用．并取得一定的疗效。目前主要应用的介入治疗方法包括：绎导管动脉灌注化疗术、经导管动脉化疗栓塞术、肝动脉、门静脉双途径化疗栓塞术、无水酒精注射术、门静脉支架置放术和超声消融术，多种方法联合治疗有望取得较好疗效。