原发性肝细胞癌合并胆管癌栓的外科治疗

目的:探讨原发性肝癌(PHC)合并胆管癌栓的外科治疗效果。方法:回顾性分析我院PHC合并胆管癌栓38例。均接受手术治疗。并比较外科手术治疗效果。单纯胆管癌栓清除 T管引流18例,肝癌切除 胆管癌栓清除 T管引流20例,其中左半肝切除10例(4例附加行肝门汇合部胆管切除及右肝管空肠Roux-Y吻合),右半肝切除 左肝管空肠吻合1例,右半肝切除2例,右肝癌肿切除 汇合部胆管切除 胆管空肠吻合2例,右肝不规则切除5例。结果:手术死亡3例,1、2、3年生存率分别为55.3％(21例)、21.1％(8例)、10.5％(4例)。单纯胆管癌栓清除患者平均存活7个月,肝癌切除患者平均存活1年8个月,最长已存活5年3个月。结论:肝癌切除 胆管癌栓清除 胆道引流术是本病最为理想的术式。胆管癌栓清除后应尽可能切除原发病灶。对术前黄疸重,肝功能失代偿,难以承受较大手术的患者,可分期手术,先癌栓清除,解除胆道梗阻,肝动脉插管栓塞化疗,争取二期肿瘤切除。单纯行胆管癌栓清除,无法根治切除,是胆管癌栓复发的根源。对于胆管癌栓术后复发,选取适当的病例再次手术,仍能取得较好的远期疗效。     

原发性肝癌合并胆管癌栓诊治进展

原发性肝癌患者出现黄疸时 ,多为肿瘤晚期 ,不宜手术治疗。但由于胆管内癌栓形成而造成阻塞性黄疸的肝癌是一种特殊类型的肝癌 ,近年来对此类型肝癌多主张采取包括手术在内的综合疗法。现将其诊治进展情况介绍如下。1　原发性肝癌合并胆管癌栓的发生机制一般认为 ,原发性肝癌通过以下途径形成胆管癌栓 :1癌细胞直接侵入薄壁的肝内胆管 ;2癌细胞通过静脉或淋巴管逆行侵入胆管壁 ;3癌细胞沿着神经鞘的间隙侵入胆管壁 ;4门静脉癌栓侵犯邻近胆管。侵入胆管的癌细胞向下持续生长 ,即造成胆管阻塞而引起黄疸 [1 ] 。2　原发性肝癌合并胆管癌栓的分…     

原发性肝癌合并胆管癌栓19例诊治体会

肝癌患者出现黄疸,可能是由于肿瘤侵犯第一肝门、压迫胆管或肝实质大量破坏所致,也可能是肝癌侵入胆管内生长或形成胆管癌栓所致。前者的治疗比较困难,后者治疗恰当可以取得良好的效果。1996-2001年,我们共收治肝癌并发胆管癌栓19例,现将诊治体会报告如下。     

肝细胞癌合并胆管癌栓1例报告

<正>胆管癌栓(bile duct tumor thrombus, BDTT)是肝细胞癌(HCC)的一种少见的脉管转移,占HCC的1.2%～12.9%^[1-2]。由于BDTT发病率低,临床医生对其影像学认识不足,且BDTT与肝门胆管癌、胆管结石等疾病鉴别诊断困难,因此在临床诊断中易造成误诊。现报道1例HCC合并BDTT患者,就其术前常规超声、增强CT等检查结合病理等相关资料进行分析讨论。1 病例资料患者女性,     

胆管癌栓致阻塞性黄疸9例外科治疗分析

目的探讨胆管癌栓致阻塞性黄疸外科治疗情况及治疗效果。方法对1990年2月至2002年8月间收治的9例原发性肝癌及胆管癌合并胆管癌栓患者的外科治疗情况进行回顾性分析和总结。结果4例行原发肿瘤及胆管癌栓根治切除术;5例行姑息性胆管癌栓清除术加T管引流术。5例患者经胆管切开癌栓清除术后黄疸症状及体征缓解1～4月,平均生存期4—6月;4例患者经左肝叶切除术或胆管癌根治术后1．5—2年内复发或远处转移。结论胆管癌栓致阻塞性黄疸并非手术治疗的禁忌,施行外科手术解决梗阻可能是一种积极的治疗方法。     

原发性肝癌合并门静脉癌栓的外科治疗

目的:探讨原发性肝癌合并门静脉癌栓的外科治疗及提高疗效的方法。方法:采用肝叶切除和经门静脉残端或主干切开取癌栓术治疗32例PHC合并PVTT患者,12例术后联合门静脉、肝动脉介入化疗,5例合并门静脉高压联合行断流术、脾切除或脾动脉结扎术。总结其临床资料、治疗方法、术后并发症及疗效预后,并进行统计学分析。结果:①本组病例术中出血量、输血量、肝门阻断次数时间、术后并发症发生率与同期50例单纯肝癌切除组比较无显著性差异(P>0.05)。②术后并发症:9例肝功能不全,3例术后肝断面出血、5例右胸腔积液、2例上消化道出血,1例术后3个月死于肝功能衰竭,其余恢复良好。③疗效与预后:随访26例,1、2、3年生存率分别为50％、34.6％、15.4％;术后化疗、术前肝功能状况对预后有显著影响。结论:肝叶切除和经门静脉残端或主干切开取癌栓是治疗原发性肝癌合并门静脉癌栓最有效的方法,改善术前肝功能及术后联合化疗,对提高生存期意义重大;门静脉取癌栓联合贲门周围血管断流、和/或脾切除、脾动脉结扎术能有效治疗肝癌合并门静脉高压,减少上消化道出血并发症;对于难以切除的PHC合并PVTT应争取行TACE术,仍有二期手术切除的机会。     

肝门胆管癌10例误诊分析

目的探讨肝门胆管癌误诊原因及早期诊断方法对10例肝门胆管癌患者的误诊作回顾性分析：本组男2例，女8例，年龄41岁～74岁．B超显示肝内胆管扩张10例，胆石症8例、阻黄玉例，胆总管占位（结石）1例．术中见肿瘤侵犯门静脉、肝动脉及肝组织形成8cm×8cm×6cm肿块8例，肿块堵塞肝总管，左肝管2例，合并胆囊结石5例，胆总管结石4例，区域淋巴结转移10例，肝脏广泛转移3例．本组行右府管肠吻合术2例，剖腹探查8例．结果诊误原因：①早期缺乏特有症状，常表现上腹不适、隐痛、乏力、黄疸等，就诊于传染科或内科，以黄疸型肝炎治疗，本组5例．②合并有胆石症，胆道手术史掩盖了胆管癌的存在，本组9例．③肝门胆管癌B超显出率低，B超医生不能准确识别其声象表现．结论肝门胆管癌病因与胆石症有关或同时存在．凡有胆系疾病史的中老年人，近期症状加重，发作频繁或出现新症状须及时就诊．B超提示肝内胆管扩张，宜进一步作CT，PTC，ERCP等检查，力争早期诊断，减少医源性延误，提高治愈率．     

肝细胞癌合并胆管癌栓诊断及治疗进展

肝细胞癌(HCC)伴胆管癌栓(HCCBDT)以HCC向胆道系统内转移致梗阻性黄疸为特点,是胆道系统最常见的继发性肿瘤,其发病率约为原发性肝癌患者的9.2%〔1〕。我国每年HC-CBDT新发病例数约为5 000～15 000人,发病率男∶女约为4∶1,发病年龄大多在35～60岁,以50岁左右为发病高峰。虽然HCCBDT发病率低,但基于我国人口基数大,罹患者绝对数量也较大。以往多认为本病已属于晚期,多持保守治疗或消极态度,致使部分HCCBDT病人丧失有效治疗机会,预后较差。     

ERCP在肝细胞癌并胆管癌栓时的应用

目的 探讨ERCP在肝细胞癌合并胆管癌栓处理中的作用。方法 回顾分析15例肝细胞癌合并胆管癌栓患者的ERCP诊疗结果。其中ERCP检查后行内镜下胆管支架引流术8例；内镜下鼻胆管引流术7例；ENBD后再行内镜下胆管金属支架引流术4例；内镜下乳头括约肌切开术后取栓及细胞刷12例。ERCP加综合治疗9例。结果 胆管造影共同表现为胆管腔内充盈缺损，可呈“球拍征”、“凝絮征”；ERCP治疗后13例有效。有效率为86．7％．ERCP后同时行综合治疗，均获良好的治疗效果。结论ERCP在肝细胞癌并胆管内癌栓的诊治中有重要作用，“球拍征”、“凝絮征”是重要胆管癌栓征象。     

原发性肝癌合并门静脉癌栓的外科治疗

肝癌是常见恶性肿瘤之一，其发病率和病死率居我国恶性肿瘤第二位。门静脉侵犯是肝癌重要的生物学特性。肝癌倾向于侵袭门静脉，并继而形成癌栓。临床报道肝癌门静脉癌栓（PVTT）发生率为44．0％～62．2％。肝癌侵袭门静脉是肝内播散及根治性切除术后早期复发的根源。此外，癌栓阻塞门静脉，门静脉高压加剧，继而引发食道胃底静脉破裂出血，甚至导致肝功能衰竭。因此，肝癌合并PVTT患者总体预后差，中位生存时间仅2．7个月。     

Surgical treatment of hepatocellular carcinoma with bile duct tumor thrombi

AIM: To study the surgical treatment effect and outcome of hepatocellular carcinoma (HCC) with bile duct tumor thrombi (BDTT). METHODS: Fifty-three consecutive HCC patients with BDTT admitted in our department from July 1984 to December 2002 were reviewed retrospectively. The clinical data, diagnostic methods, surgical procedures and outcome of these patients were collected and analyzed. RESULTS: One patient rejected surgical treatment, 6 cases underwent percutaneous transhepatic cholangial drainage (PTCD) for unresectable primary disease, and the other 46 cases underwent surgical operation. The postoperative mortality was 17.6%, and the morbidity was 32.6%. Serum total bilirubin levels of these patients with obstructive jaundice decreased gradually after surgery. The survival time of six cases who underwent PTCD ranged from 2 to 7 mo (median survival of 3.7 mo). The survival time of the patients who received surgery was as follows: 2 mo for one patient who underwent laparotomy, 5-46 mo (median survival of 23.5 mo, which was the longest survival in comparison with patients who underwent other procedures, P=0.0024) for 17 cases who underwent hepatectomy, 5-17 mo (median survival of 10.0 mo) for 5 cases who underwent HACE, 3-9 mo (median survival of 6.1 mo) for 11 cases who underwent simple thrombectomy and biliary drainage, and 3-8 mo (median survival of 4.3 mo) for four cases who underwent simple biliary drainage. CONCLUSION: Jaundice caused by BDTT in HCC patients is not a contraindication for surgery. Only curative resection can result in long-term survival. Early diagnosis and surgical treatment are the key points to prolong the survival of patients.     

肝细胞癌伴门静脉癌栓的手术治疗

门静脉癌栓(PVTT)是肝细胞癌(简称肝癌)重要的生物学特性,也是其严重并发症和转移方式,手术切除仍然是目前肝癌伴PVTT最有效的治疗方法。介绍了肝癌伴PVTT手术治疗的历史与现状、PVTT形成的解剖学基础、PVTT分型、手术适应证、术式选择以及手术疗效评价。认为在循证医学的基础上建立个体化多学科治疗模式,可能是肝癌伴PVTT治疗的发展方向。     

Surgical treatment for hepatocellular carcinoma with portal vein tumor thrombus

BACKGROUND/AIMS: To study the value of surgical treatment for hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT). METHODOLOGY: From January 1997 to December 2001, 63 cases of HCC with portal vein tumor thrombus underwent liver resection combined with PVTT removal (group 1). Between December 2001 and December 2003, 20 patients received adjuvant portal vein chemotherapy (PVC) after the surgical procedures mentioned above (group 2). Treatment outcome and the surgical features in these two groups were studied. RESULTS: The median overall survival in group 2 was significantly longer than that in group 1 (10.9 months vs. 7.8 months, p < 0.05). There were significant differences between the survival of the two groups (log-rank, p < 0.05). In group 1 the 1-, 3-, and 5-year survival rates were 18.0%, 14.8% and 1.6%, respectively. In group 2 the 1-year survival rate was 30%. CONCLUSIONS: Liver resection combined with PVTT removal and the postoperative PVC is beneficial to the survival of HCC patients with PVTT. Postoperative PVC might enhance the effect of these surgical approaches.     

Surgical treatment for advanced hepatocellular carcinoma with portal vein tumor thrombus

The Barcelona Clinic Liver Cancer staging system recommends a tyrosine kinase inhibitor (sorafenib) as standard therapy in advanced hepatocellular carcinoma (HCC) patients with portal vein tumor thrombus (PVTT). Sorafenib has been shown to prolong median overall survival (OS) by approximately 3 months in advanced HCC patients with PVTT (8.1 vs. 4.9 months). However, its clinical effectiveness is still controversial and standard treatment with sorafenib is not established in Japan. Surgical resection is considered a potentially curative treatment and provides an acceptable outcome for carefully selected patients. The surgical mortality rate in patients with PVTT who receive surgical resection ranges from 0% to 10%. The median survival time and 1-year OS rate in HCC patients with PVTT who undergo surgical resection have been found to range from 8 to 22 months and 21.7% to 69.6%, respectively. But improvement in therapeutic outcome is difficult with surgical treatment alone. Combination treatment in conjunction with such methods as transarterial chemoembolization, hepatic artery infusion chemotherapy, and radiotherapy has been found to improve the prognosis (median survival time, 11.5–37 months; 1-year OS rate, 46.8–100%). Yet, many problems remain, such as surgical indications and surgical techniques. After resolving these points, a multidisciplinary strategy based on surgical treatment should be established for advanced HCC with PVTT.     

Outcomes of hepatectomy for hepatocellular carcinoma with bile duct tumour thrombus

Background

Hepatocellular carcinoma (HCC) with bile duct tumour thrombus (BDTT) is rare. The aim of the present study was to determine the prognosis of HCC with BDTT after a hepatectomy.

Methods

A retrospective analysis was performed on all HCC patients with BDTT having a hepatectomy from 1989 to 2012. The outcomes in these patients were compared with those in the control patients matched on a 1:6 ratio.

Results

Thirty-seven HCC patients with BDTT having a hepatectomy (the BDTT group) were compared with 222 control patients. Patients in the BDTT group had poorer liver function (43.2% had Child–Pugh B disease). More patients in this group had a major hepatectomy (91.9% versus 27.5%, P = 0.001), portal vein resection (10.8% versus 1.4%, P = 0.006), en-bloc resection with adjacent structures (16.2% versus 5.4%, P = 0.041), hepaticojejunostomy (75.7% versus 1.6%, P < 0.001) and complications (51.4% versus 31.1%, P = 0.016). The two groups had similar hospital mortality (2.7% versus 5.0%, P = 0.856), 5-year overall survival (38.5% versus 34.6%, P = 0.59) and 5-year disease-free survival (21.1% versus 20.8%, P = 0.81). Multivariate analysis showed that lymphovascular permeation, tumour size and post-operative complication were significant predictors for worse survival whereas BDTT was not.

Discussion

A major hepatectomy, extrahepatic biliary resection and hepaticojejunostomy should be the standard for HCC with BDTT, and long-term survival is possible after radical surgery.     

Prognosis of hepatocellular carcinoma with bile duct tumor thrombus after R0 resection:a matched study

BACKGROUND: Hepatocellular carcinoma (HCC) with bile duct tumor thrombus (BDTT) is rare. The present study aimed to determine post-surgical prognoses in HCC patients with BDTT, as outcomes are currently unclear.
METHODS: We compared the prognoses of 110 HCC patients without BDTT (group A) to 22 cases with BDTT (group B). The two groups were matched in age, gender, tumor etiology, size, number, portal vascular invasion, and TNM stage. Addi-tionally, 28 HCC patients with BDTT were analyzed to identify prognostic risk factors.
RESULTS: The 1-, 3-, and 5-year overall survival rates were 90.9%, 66.9%, and 55.9% for group A and 81.8%, 50.0%, and 37.5% for group B, respectively. The median survival time in groups A and B was 68.8 and 31.4 months, respectively (P=0.043). The patients for group B showed higher levels of serum total bilirubin, alanine aminotransferase and gamma-glutamyl transferase, a larger hepatectomy range, and a higher rate of anatomical resection. In subgroup analyses of patients with BDTT who underwent R0 resection, TNM stage III-IV was an independent risk factor for overall survival; these patients had worse prognoses than those with TNM stage I-II after R0 resection (hazard ratio=6.056,P=0.014). Besides, univariate and multivariate analyses revealed that non-R0 resection and TNM stage III-IV were independent risk fac-tors for both disease-free survival and overall survival of 28 HCC patients with BDTT. The median overall survival time of patients with BDTT who underwent R0 resection was longer than that of patients who did not undergo R0 resection (31.0 vs 4.0 months,P=0.007).
CONCLUSIONS: R0 resection prolonged survival time in HCC patients with BDTT, although prognosis remains poor. For such patients, R0 resection is an important treatment that determines long-term survival.     

Diagnosis of bile duct hepatocellular carcinoma thrombus without obvious intrahepatic mass

AIM:To study the diagnosis of hepatocellular carcinoma(HCC)presenting as bile duct tumor thrombus with no detectable intrahepatic mass.METHODS:Six patients with pathologically proven bile duct HCC thrombi but no intrahepatic mass demonstrated on the preoperative imaging or palpated intrahepatic mass during operative exploration,were collected.Their clinical and imaging data were retrospectively analyzed.The major findings or signs on comprehensive imaging were correlated with the surgical and pathologic findings.RESULTS:Jaundice was the major clinical symptom of the patients.The elevated serum total bilirubin,direct bilirubin and alanine aminotransferase levels were in concordance with obstructive jaundice and the underlying liver disease.Of the 6 patients showing evidence of viral hepatitis,5 were positive for serum alpha fetoprotein and carbohydrate antigen 19-9,and 1 was positive for serum carcinoembryonic antigen.No patient was correctly diagnosed by ultrasound.The main features of patients on comprehensive imaging were filling defects with cup-shaped ends of the bile duct,with large filling defects presenting as casting moulds in the expanded bile duct,hypervascular intraluminal nodules,debris or blood clots in the bile duct.No obvious circular thickening of the bile duct walls was observed.CONCLUSION:Even with no detectable intrahepatic tumor,bile duct HCC thrombus should be considered in patients predisposed to HCC,and some imaging signs are indicative of its diagnosis.     

Curative resection of hepatocellular carcinoma with intrabile duct tumor growth mimicking hilar bile duct carcinoma

A 62-year-old Japanese male was admitted with obstructive jaundice and underwent percutaneous transhepatic cholangiodrainage (PTCD). An initial diagnosis was made of hilar bile duct carcinoma, based on demonstrated irregular stenosis of the hilar hepatic bile ducts without obvious tumor within the liver and negative alpha-fetoprotein (AFP). Enhanced computed tomography (CT) showed an irregular low density area around the hepatic hilum and the umbilical portion of the portal vein, suggesting carcinomatous invasion with blood flow disturbances. In contrast, intraoperative ultrasonography (US) raised the suspicion of an ill-defined lesion in Couinaud's segment 2 (segment 2) and intrabile duct tumor formation. A radical extended left and caudate lobectomy of the liver was successfully performed, with additional resection of extrahepatic bile duct and enbloc resection of regional lymph nodes. Unexpectedly, histological analysis of the resected specimen showed the final diagnosis to be hepatocellular carcinoma (HCC) of segment 2 with intrabile duct tumor growth. This case demonstrates that HCC with intrabile duct tumor growth toward the heptic hilum can mimic hilar bile duct carcinoma, when the tumor itself is equivocal on preoperative imaging and AFP is negative. In such cases, intraoperative US and guided biopsy may be of value for definitive diagnosis and selection of the optimal procedure.     

Recurrence hazard rate in patients with hepatocellular carcinoma and bile duct tumor thrombus: a multicenter observational study

BackgroundPatients with hepatocellular carcinoma (HCC) bile duct tumor thrombus (BDTT) have a high rate of postoperative recurrence. We aimed to describe the patterns and kinetics of recurrence in BDTT patients and provide management options accordingly.MethodsThis retrospective study included 311 HCC patients with BDTT who underwent surgery from 2009 to 2017 at five centers in China. The hazard rate of recurrence was calculated using the hazard function.ResultsThe hazard rate of intrahepatic recurrence was higher than that of extrahepatic recurrence (0.0588 vs. 0.0301), and both showed a decreasing trend, and the intrahepatic recurrence and extrahepatic recurrence risk decreased to a lower level after 40 and 20 months, respectively. Patients who underwent anatomic resection had a consistently lower hazard rate of recurrence than patients who underwent nonanatomic resection, whereas patients who received postoperative adjuvant transarterial chemoembolization (TACE) mainly had a lower hazard rate of recurrence in the first year than patients who did not.ConclusionThe follow-up of BDTT patients should be at least 40 months because of its high rate of recurrence, in parallel with the need for vigilance for extrahepatic recurrence within 20 months. Anatomic hepatectomy and adjuvant TACE are recommended to improve BDTT patient outcomes.