胃癌合并门静脉癌栓的CT表现

为了提高对胃癌合并门静脉癌栓CT表现的认识,回顾性分析1990年5月23日~2005年9月18日7例经胃镜、手术病理及临床确诊的胃癌合并门静脉癌栓患者的资料。7例患者均行CT平扫加增强检查。CT检查均显示胃病变区胃壁明显不规则增厚,3例患者出现肝转移灶。门脉癌栓栓子发生的部位主要位于门脉主干段(7例),其中2例累及左、右分支;1例累及肠系膜上静脉;1例同时累及肠系膜上静脉和脾静脉。7例患者中有5例癌栓未见明显强化,2例患者增强后癌栓轻度强化。5例患者癌栓的所在门脉主干明显扩张,门脉血流阻断,5例患者扩张的门脉主干周围可见明显强化迂曲的侧枝血管影,其中2例出现大量腹水。研究结果显示,虽然绝大部分门静脉癌栓由原发性肝癌引起,但门静脉癌栓也可以是由进展期胃癌形成,密切结合临床资料,两者鉴别诊断并不困难。     

Portal vein thrombosis after splenectomy for gastric malignant lymphoma

Portal vein thrombosis (PVT) has rarely been documented in patients after splenectomy for gastric malignancy. We report a case of PVT that occurred after splenectomy as part of an en-bloc node dissection performed to treat gastric malignant lymphoma. A 38-year-old man underwent total gastrectomy and splenectomy with en-bloc D2 lymph node dissection. The spleen weighed 480g. On postoperative day (POD) 31, the patient complained of abdominal pain in the right upper quadrant accompanied by fever. Moderate elevations of C-reactive protein (CRP), aspartate transaminase (AST), and alanine transaminase (ALT) were noted. Contrast-enhanced computed tomography (CT) and ultrasonography disclosed thrombus in the portal vein and the splenic vein. There were no abnormalities in the levels of lupus anticoagulant, protein C antigen, protein S antigen, or antithrombin III (AT III). A diagnosis of PVT was made, and prompt treatment, including intravenous heparin combined with tissue plasminogen activator (tPA) was initiated, followed by longterm warfarin. This treatment resulted in clinical improvement, but failed to achieve thrombolysis in the portal vein. At follow-up after 6 months, the patient complained of postprandial abdominal pain with persistent peripheral edema and ascites. This case indicates that splenectomy for en-bloc node dissection in gastric malignancy is a possible cause of PVT. Because both the symptoms and the laboratory data in PVT are nonspecific, a high level of clinical suspicion and a low threshold for obtaining imaging examinations are important in the early diagnosis of PVT. Surgeons should remember PVT among several other complications whenever patients treated with radical gastrectomies are symptomatic and imaging studies are considered necessary.     

A case report of hepatocellular carcinoma with hepatic and portal venous tumor thrombus and multiple intrahepatic metastasis who survived over 1 year after the operation with combined locoregional chemotherapy

Hepatocellular carcinoma (HCC) with vascular invasion and/or intrahepatic metastasis (IM) has a poor prognosis, so advanced HCC may be considered as a contraindication for hepatectomy. We experienced a case of HCC with hepatic venous and portal venous tumor thrombus and multiple IM who survived over 1 year after the operation with combined locoregional chemotherapy. (Case): A 67-year-old male patient was diagnosed with HCC with extracapsular invasion after transarterial embolization (TAE). CT scan revealed the HCC had a right portal venous tumor thrombus and multiple IM. Posterior lobectomy and thrombectomy of hepatic venous and portal venous tumor thrombus and placement of portal venous catheter ware performed. From the first day after operation the patient received continuous intravenous and intraportal 5-FU for 3 weeks. At the first month after operation, TAE and PEIT were given against residual IM. After discharge the patient received hepatic arterial infusion chemotherapy (MTX/CDDP/5-FU/Leucovorin). Fourteen months after operation, the patient is surviving in good physical condition.     

肝癌的螺旋CT表现及鉴别诊断

目的　对 5 4例肝细胞性肝癌的螺旋CT双期扫描表现进行分析 ,探讨其在肝癌诊断及鉴别诊断中的价值。方法　对全部病例行全肝平扫和增强扫描。注射造影剂后 2 5s开始肝动脉期扫描 ,70s开始门脉期扫描。观察全部病灶在双期增强扫描中的表现。结果　肝动脉期扫描共发现病灶 72个 ,其中 2 8个病灶表现为均匀强化 ,40个为不均匀强化 (其中 4个还可见到供血动脉 ) ,另有 4个无明显强化。门脉期扫描中发现 6 2个病灶 ,均为低密度 ,其中 8例可见到门脉癌栓形成 ,另有 7个病灶可见到假包膜形成。结论　螺旋CT双期增强扫描可充分反映肝细胞性肝癌的特征 ,有利于诊断和鉴别诊断。     

‘Benign’ hepatic portal venous gas

The presence of portal venous gas within the hepatic parenchyma is usually associated with a guarded prognosis and a mortality rate approaching 75%. However, there are infrequent causes of portal venous gas not associated with dire clinical outcomes. We describe three patients who made uneventful clinical recoveries after presenting with clinical and imaging manifestations of ischaemic bowel and hepatic portal venous gas, two of which had distended but non‐necrotic bowel at laparotomy.     

肝脏局灶性结节增生的螺旋CT平扫及三期增强扫描

目的 分析肝脏局灶性结节增生（FNH）的螺旋CT平扫及三期增强扫描表现,以提高对FNH的诊断准确率。方法对21例21个经手术病理证实的FNH进行螺旋CT平扫及增强的动脉期、门脉期、延迟期扫描。其中2例行肝动脉血管造影。结果 21个FNH,平扫16个为低密度,5个为等密度,其中12个病灶中央有点状、条状、放射状低密度影。动脉期21个FNH除中央疤痕外,均明显均匀强化,9例见明显增粗的供血动脉;门脉期病灶密度下降,但均高于或略高于肝实质;延迟期病灶呈等密度或略低于肝实质,3例见包膜强化。血管造影可见粗大的供血动脉及引流静脉。结论 FNH在螺旋CT平扫及三期增强扫描中的特征性表现,对FNH的确诊及治疗方案的选择有重要价值。     

Segmental hyperattenuation in the liver as a result of right hepatic vein thrombosis: An unusual complication of central venous catheterization

Liver perfusion disorder secondary to hepatic vein occlusion is not often reported. This abnormality might be caused by invasion of the hepatic veins by tumour or compression by a large right adrenal mass. We present an unusual cause of hepatic perfusion disturbance due to right hepatic vein thrombosis resulting from inadvertent hepatic venous catheterization. On contrast‐enhanced CT, the tip of a central venous catheter extended into the right hepatic vein, which was thrombosed. A sharply marginated wedge‐shaped hyperdense region was demonstrated in the right lobe of the liver, thought to represent a compensatory increase in arterial flow to the affected territory.     

A case of Vp4 hepatocellular carcinoma treated with surgical resection and continuous intrahepatic artery infusion chemotherapy of low-dose cisplatin and 5-fluorouracil

A 49-year-old woman was admitted to our hospital because of hepatocellular carcinoma (HCC). She had no hepatitis virus. Serum AFP and PIVKA-II levels were as high as AFP 329.4 ng/ml (AFP-L3% 73.1%) and 281 AU, respectively. Portal venous thrombus was observed from the right portal branch to left portal branch and superior mesenteric vein. An extended right hemihepatectomy with extraction of portal venous thrombus was performed. On postoperative day 8, low-dose cisplatin (10 mg/day for 5 days/week) and 5-fluorouracil (250 mg/day for 5 days/week) were administered through the hepatic artery for 4 weeks. After chemotherapy, one intrahepatic metastasis appeared and RFA was performed for this tumor. At 16 months after surgery, she had multiple lymph node metastases and died at 20 months after the surgery without intrahepatic metastasis. Low-dose CDDP/5-FU intra-hepatic artery infusion chemotherapy was effective for prevention of intrahepatic recurrence after resection of HCC with portal venous thrombus.     

Computer Tomography and Magnetic Resonance Image Manifestations of Primary Hepatic Neuroendocrine Cell Carcinomas

Aim: This study aims to investigate the manifestation of CT, MRI and dynamic enhanced scans for primaryhepatic neuroendocrine cell carcinoma. Methods: CT or MRI arterial and venous phase scan images of 19cases of pathologically confirmed PHNEC were retrospectively analyzed. Results: 14 cases (73.68%) with singlelesion, 5 cases (26.3%) with multiple lesions, with an average diameter of 13.2 cm. Some 12 cases (63.16%)showed inhomogeneous enhancement, seven cases (36.8%) showed homogeneous enhancement, 13 cases (68.4%)demonstrated significant enhancement in the arterial phase, 13 cases (68.4%) had significantly enhanced portalvenous phase including 7 cases (36.8 %) with portal venous phase density or signal above the arterial phaseand 5 cases (26.3%) with the portal vein density or signal below the arterial phase. Seven cases (36.8%) hadcontinued strengthened separate shadows in the center of the lesion. Thrombosis were not seen in portal veins.Conclusion: CT and MRI images of liver cell neuroendocrine carcinoma have certain characteristics that canprovide valuable information for diagnosis and differential diagnosis.     

Peripherally inserted central catheters and upper extremity deep vein thrombosis

The purpose of the study was to determine the incidence and risk factors for venous thrombosis in patients with a peripherally inserted central catheter (PICC). A retrospective study of all upper extremity venous duplex scans was carried out in the Vascular Medicine department from year 2000 to 2002 inclusive. A chart review of positive scans was undertaken to identify possible thrombotic risk factors. Of 317 upper extremity venous duplex scans carried out, 115, or 32%, were positive for upper extremity deep vein thrombosis. Three main risk factors were identified – presence of a central line, malignancy and administration of chemotherapy. PICC were the most common central line present. Symptomatic thrombosis occurred in 7% of PICC inserted for chemotherapy compared with 1% of PICC inserted for other reasons. Ten per cent of the patients receiving chemotherapy through a PICC developed a thrombosis. The post‐thrombotic syndrome was infrequent following upper extremity deep vein thrombosis. Patients receiving chemotherapy through a PICC are at increased risk of thrombosis. There may be a role for prophylactic low‐dose anticoagulation in these high‐risk patients.     

A case of Vp3 hepatocellular carcinoma with a good QOL after multidisciplinary treatments

A 74-year-old male was examined with abdominal CT scan because of general fatigue. Abdominal CT scan indicated enhanced tumors, 9x8 cm in size in subsegment 6/7 and 5 mm in size in subsegment 3. Tumor thrombus was observed in the right portal branch to the main portal vein. We diagnosed the patient with Vp3 hepatocellular carcinoma. A right hepatectomy with extraction of portal venous thrombus was performed. Unresectable tumor was treated with one shot arterial infusion (epi-ADM 40 mg) and TAE 3 times at an interval of three months. The side effect was only a fever and the QOL was good under the treatment. But a tumor in S1 had developed, and the patient died at about 12 months after the operation.     

Sixty-four multi-detector computerised tomography in the detection of lower gastrointestinal bleeding: A prospective study

Introduction: Acute gastrointestinal bleeding (AGIB) is a serious and life‐threatening condition. Many diagnostic procedures and tests are being used to detect the site of bleeding with different success rates. The aim of our study is to prospectively evaluate accuracy of 64‐slice multi‐detector computerised tomography (MDCT) in the diagnosis of lower AGIB. Methods: Between September 2007 and January 2009, patients with presumed lower AGIB were referred to the radiology department of our institution for 64‐slice MDCT examination as part of the investigation for the lower AGIB. Any abnormalities to account for bleeding, such as tumours, bowel wall enhancement and increased intraluminal density, were recorded. Results: Out of 139 patients with AGIB that were admitted to our casualty department, 27 patients (19 men and 8 women) in the age range of 24–88 years (mean age, 56 years) were suspected to have lower AGIB. Sixty‐four‐slice MDCT was performed and considered positive for bleeding in 19 (70%) cases, and in all the cases, the bleeding source was indentified in the arterial phase, showing a focal dense wall enhancement in 8 (42%) cases, circumferential wall enhancement in 4 (22%) cases and progressive increasing intraluminal density in 7 (36%) cases. The venous phase scan showed increased dispersion of the contrast within the lumen as an additional clue for active extravasation in 15 (79%) out of the 19 cases. Delayed 5‐min scanning showed the same findings as venous phase in all the 19 positive cases and failed to depict any additional findings in the eight cases that were negative on arterial or venous phases. Conclusion: The study supports the high accuracy of 64‐slice MDCT in locating the site of AGIB in patients thought to have a distal source of bleeding. Its accuracy in clinically proximal bleeding is not clear from this study, but MDCT is capable of showing such sources.     

Investigation of acute lower gastrointestinal bleeding with 16‐ and 64‐slice multidetector CT†

We evaluated the usefulness of 16‐ and 64‐slice multidetector CT (MDCT) in the detection of a bleeding site in acute lower gastrointestinal tract (GIT) haemorrhage by conducting a retrospective study of cases of presumed acute lower GIT haemorrhage imaged with CT in two teaching hospitals in an 11‐month period. The patients underwent contrast enhanced CT using either a 16 or 64 MDCT. No oral contrast was used. One hundred milliliters of non‐ionic intravenous contrast agent was injected at 4.5 mL/s, followed by a 60 mL saline flush at 4 mL/s through a dual head injector. Images were acquired in arterial phase with or without non‐contrast and portal phase imaging with 16 × 1.5 mm or 64 × 0.625 mm collimation. Active bleeding was diagnosed by the presence of iodinated contrast extravasation into the bowel lumen on arterial phase images with attenuation greater than and distinct from the normal mucosal enhancement or focal pooling of increased attenuation contrast material within a bowel segment on portal‐venous images. Further management and final diagnosis was recorded. Fourteen patients and 15 studies were reviewed. CT detected and localized a presumed bleeding site or potential causative pathology in 12 (80%) of the patients. Seven of these were supported by other investigations or surgery, while five were not demonstrated by other modalities. Eight patients had mesenteric angiography, of which only four corroborated the site of bleeding. CT did not detect the bleeding site in three patients, of which two required further investigation and definitive treatment. We propose that MDCT serves a useful role as the initial rapid investigation to triage patients presenting with lower GIT bleeding for further investigation and management.     

Radiographic Manifestations of Clostridial Infection Encountered at Queen Elizabeth Hospital,Adelaide

Cases of cholecystitis emphysematosa, ante-mortem gas in the portal venous system, and primary clostridial pneumonia were presented and literature reviewed. No gall-stones were demonstrated in the cholecystitis emphysematosa, demonstrating that obstruction of the cystic duct is not an essential aetiological factor. This patient was not a diabetic. The case of the gas in the portal venous system is of particular interest as the portal sepsis was an aftermath of perforation of primary non-specific jejunal ulcer which in the opinion of clinicians and pathologists involved was secondary to sarcoid granuloma. This patient was a diabetic. There was no evidence of mesenteric artery occlusion, pneumatosis intestinalis or gross distension of loops of bowel, thus lending support to the theory of sepsis of the portal venous system by gas-producing organisms. The primary clostridial pneumonia in the patient suffering from acute myeloid leukaemia was diagnosed at autopsy. This was characterized radiographically by dense consolidation of the right upper lobe, which within 18 hours progressed to widespread abscess formation.     

动态监测D-二聚体在肿瘤患者导管相关性血栓的临床意义

目的 探讨D-二聚体水平与肿瘤患者导管相关性血栓(Catheter related thrombosis,CRT)发生的相关性。方法 对100例住院的深静脉置管肿瘤患者进行前瞻性研究,动态监测血浆D-二聚体以及静脉多普勒超声检查,观察CRT的发生率、发生时间及血栓类型等。结果 CRT的发生率为12.6%,其中无症状血栓占83.3%。58.3%的血栓发生在置管后2周内,91.7%发生在置管后的置管后4周内。置管后2周血栓组D-二聚体水平显著高于非血栓组(P=0.013)。结论 肿瘤患者CRT大部分形成于深静脉置管后4周内,其中无症状性血栓的比例高,动态监测D-二聚体可能有助于其早期诊断。     

A complete response to one-shot hepatic arterial infusion of epirubicin in a patient with highly advanced hepatocellular carcinoma

A 61-year-old male was admitted for advanced hepatocellular carcinoma (HCC) with multiple lung metastases and tumor thrombus in the portal vein and superior vena cava. At first, we planned to perform transcatheter arterial embolization (TAE) to avoid the rupture of the liver tumor. But, due to the severe liver dysfunction, ie Child-Pugh C and 36% ICG R15, hepatic arterial infusion (HAI) of epirubicin 40 mg was performed. After that, the patient was followed at the outpatient ward and his general condition has gradually improved without a special treatment. At the present, one year and ten month after HAI, the serum alpha-fetoprotein (AFP) is almost within normal limits and CT scans show that HCC with multiple lung metastases, and tumor thrombus in the portal vein and superior vena cava almost disappeared. Although, spontaneous regression of HCC was a rare phenomenon, it might have played a major role in the good anticancer efficacy of this patient as well as high anti-cancer agent sensitivity of his liver tumor.     

高强度聚焦超声治疗门静脉癌栓的初步临床观察

目的:探讨高强度聚焦超声(high intensity focused ultrasound,HIFU)治疗门静脉癌栓(portal vein tumor thrombosis, PVTT)的安全性和有效性。方法:应用FEP-BY01型肿瘤超声治疗机对42例原发性肝癌合并的门静脉癌栓进行HIFU治疗。结果:HIFU治疗后31％(13／42)癌栓消失;33．3％(14／42)癌栓部分消失; 35．7％癌栓不消失。未发生皮肤烧伤、出血和胃肠道穿孔等并发症。结论:HIFU治疗PVTT是一种新的和安全有效的局部治疗方法。     

A case report of hepatocellular carcinoma (Vp4)--an attempt to reduce residual tumor thrombus using combination therapy (hepatic arterial infusion, hepatic arterial embolization and radiation)

A 57-year-old man was found to have elevated levels of HCC markers during an observation of chronic hepatitis C. Diffused hepatoma was involved in the posterior lobe, and tumor thrombus extended into the main portal vein (Vp4). Posterior segmentectomy and tumor thrombectomy were performed. But, CT scan 45 days after the operation showed an enhancement at the residual tumor thrombus in the posterior branch. The patient received a hepatic arterial infusion of 5-FU, followed by hepatic arterial embolization. Then, we chose radiation therapy to the tumor thrombus. The most recent CT showed no enhancement at the reduced tumor thrombus. There have been almost no reports of treatment for residual portal thrombus. Careful observations are necessary in such patients.     

胰腺囊性良恶性病变的CT诊断

目的分析胰腺囊性病变的CT表现, 提高胰腺病变的CT诊断准确率。方法 回顾分析经手术、病理证实的22例胰腺囊性病变的CT表现。螺旋CT机为TOSHIBA Aquilion 16多层螺旋CT机, 采用平扫和双期(动脉期, 门静脉期)增强扫描, 层厚7.0mm, 螺距1.0, 非离子型碘对比剂总量100mL, 注射流率3mL/s, 动脉、门脉期扫描分别为30s和70s。结果 胰腺假性囊肿12例, 平扫为囊状水样密度影, 增强扫描囊壁轻度强化, 内无分隔。胰腺脓肿4例, 平扫为类圆形液性密度, CT值为24Hu左右, 内见小气泡影, 增强扫描囊壁呈环形明显强化。胰腺囊腺瘤4例, 平扫为类圆形的水样或肌肉样密度影, 增强扫描囊壁分隔及壁结节呈不规则强化, 囊壁厚度＜2mm。胰腺囊腺癌2例, 平扫呈囊状水样密度及壁结节, 其内有分隔, 增强扫描囊壁、壁结节及分隔可见不规则明显强化, 囊壁厚度＞2mm, 1例伴有肝内转移及腹膜后淋巴结转移。结论 胰腺囊性病变有各自的CT特征, 但相似之处较多, 结合临床病史、必要时密切随访加以鉴别, 可提高胰腺病变的CT诊断准确率。     

Visceral Thromboses in Pancreas Adenocarcinoma: Systematic Review

Within gastrointestinal malignancies, primary hepatocellular carcinoma and pancreatic ductal adenocarcinoma (PDAC) are frequently associated with visceral thromboses (VT). Thrombus formation in the portal (PVT), mesenteric (MVT), or splenic vein (SVT) system leads to portal hypertension and intestinal ischemia. VT in PDAC may convey a risk of increased distal thrombosis and poses therapeutic uncertainty regarding the role of anticoagulation. An increasing number of reports describe VT associated with PDAC. It is possible that early diagnosis of these events may help reduce morbidity and speculatively improve oncologic outcomes. To perform a systematic review to study PVT, MVT, and SVT associated with PDAC, and to provide a comprehensive review. Medline/PubMed, Embase, Web of Science, Scopus, and the Cochrane Library. Data Extraction and Assessment: Two blinded independent observers extracted and assessed the studies for diagnosis of PVT, MVT, and SVT in PDAC. Studies were restricted to English-language literature published between 2007 and 2016. Eleven articles were identified. Five case reports and 7 retrospective studies were found, with a total of 127 patients meeting the inclusion criteria. The mean age at diagnosis was 64 years. PVT was found in 35% (n = 46), SVT in 52% (n = 65), and MVT in 13% (n = 15). Mean follow-up time was 26 months. Only 3 of the selected articles studied the impact of anticoagulation in VT. All patients with nonvisceral thrombosis (eg, deep-vein thrombosis, pulmonary emboli) were therapeutically treated; in contrast, patients with VT only rarely received treatment. VT in PDAC is a frequent finding at diagnosis or during disease progression. Evidence to guide treatment choices is limited, and current management is based on inferred experience from nononcologic settings. Anticoagulation appears to be safe in VT, with most of the large studies recommending a careful assessment for patients at a high risk of bleeding.