经导管^192lr近距离放射治疗局部晚期肝门部胆管癌

目的：观察局部晚期肝门部胆管癌姑息性引流术后＾１９２ｌｒ腔内放疗的疗效。方法：先行手术探查尽可能刮除肿瘤并放置Ｕ型管引流，术后再经导管腔内放疗。参考点距离放射源中心轴１０ｍｍ，总量２４－３０Ｇｙ／３次，３例配合肝动脉区域性灌注化疗，１例配合外照射ＤＴ４５Ｇｙ／４．５周。结果：生存期６－２６个月，中位生存期１１．５月。１５例死亡，１例目前存活８个月。全组１年生存率３７．５％，２年生存率６．０％，结论     

局部晚期肝门部胆管癌根治术后放射治疗

目的回顾性分析及评价肝门部胆管癌根治性术后放射治疗的结果.方法 1992年3月～1997年12月76例肝门部胆管癌患者接受根治性手术,其中47例术后病理显示切缘有镜下残留(R1组),47例中28例接受术后放射治疗(S RT组),6～15MV X线外照射,靶区剂量达45～62Gy,中位剂量52Gy.术后中位随访期30个月(4～113个月).结果(n=47)总5年生存率28%,中位生存期19.6个月.S RT组(n=28)5年生存率、中位生存期显著高于S组(n=19),分别为34%、29个月和14%、10.0个月(P=0.0141).结论根治性手术结合放射治疗可明显延长切缘阳性患者的生存期;早、晚期放射反应可以耐受.     

局部晚期肝门部胆管癌根治术后放射治疗

Objective： To evaluate the outcome of radiotherapy （RT） in locally advanced hepatic hilar cholangiocarcinoma. Methods： During March 1992 to December 1997, 47 patients who had positive microscopic surgical margins after surgery were treated by postoperative radiotherapy （S＋RT, 28 patients, with a median dose of 50 Gy, 45-62 Gy） and surgery alone （S, 19 patients）. The median follow-up was 30 months （4-113 months）. Results： The overall 5-year survival rate was 28%, with a median survival length of 19.6 months while 5-year survival rates of S＋RT group and S group were 34% and 14%, with median survival lengths of 29 and 10 months respectively （P=0.015）. The occurrence rate of complications was 11% in either group. Conclusion： Postoperative radiotherapy significantly prolongs survival lengths in patients with hepatic hilar cholangiocarcinoma who had positive microscopic surgical margins. Radiation toxicities are tolerable.     

肝门部胆管癌的放射治疗

随着肝门部胆管癌手术技术方法的改善,放射治疗设备更新及技术方法的提高,放射治疗在肝门部胆管癌治疗中的应用亦增多.全文综述近年来的相关文献,以阐述放射治疗在肝门部胆管癌治疗中的价值.     

右前叶肝管外引流治疗晚期肝门部胆管癌

本介绍右前叶肝管外引流治疗晚期肝门部胆管癌的手术方法及治疗结果。术后胆汁引流量平均300-400ml/24h,2周后血清胆红素下降平均值153.9μmol/L。通过引流管造影表明右半肝胆管扩张有不同程度改善.经1.5-2年随访观察，存活期平均9.5个月，作认为此法操作容易，安全，胆道减压引流较充分，能延长患生存期。     

肝门部胆管癌的诊断及不可切除肝门部胆管癌的治疗研究进展

肝门部胆管癌（hilar cholangiocarcinoma,HCCA）在亚洲的发病率较高,我国是发病率及死亡率最高的国家之一。HCCA早期症状隐匿,临床诊断较为困难,患者就诊时多处于癌症晚期,失去手术机会;对于不可切除HCCA,不同治疗方法的疗效不尽相同。本文基于一些现有的临床试验,对HCCA的诊断及不可切除HCCA的治疗研究进展进行综述,旨在为HCCA的临床诊断及治疗提供参考。     

肝门部胆管癌放射治疗的进展

肝门部胆管癌或称高位胆管癌是指发生于左右肝管及其汇合部的恶性肿瘤，左右肝管汇合部的恶性肿瘤又称为Klastin瘤，占肝外胆管癌(extrahepatic bile duct cancer,EHBDC)的58％～75％。目前手术切除仍是其根治的惟一方法。由于其发病隐匿，确诊时多为晚期，以及肝门部特殊的解剖关系，肝门部胆管癌的手术切除率及切净率均较低。放射治疗以往多用于无法切除、复发患者的姑息性治疗，由于治疗增益有限，故认为胆管癌具有放射抗拒性。近10余年来，     

肝门部胆管癌的外科治疗

胆管癌是罕见的恶性肿瘤,可以发生于肝内外胆道的任何部位,最常累及肝门周围肝管汇合处。近年来,肝门部胆管癌的发病率有上升趋势,对其治疗手段也有突破性进展。我院近１５年收治肝门部胆管癌８９例,现将外科治疗体会报告如下。材料与方法临床资料：肝门部胆管癌８９...     

U管引流在晚期肝门部胆管癌治疗中的应用体会

目的 探讨U管引流在不能切除肝门部胆管癌姑息治疗中的应用价值。方法 对8例晚期肝门部胆管癌行U管引流姑息治疗病例的方法，疗效进行分析。结果 除1例术后死于肝衰，其余7例均黄疸消退，营养改善。5例存活1年，3例存活2年，存活率分别为62．5％(5／8)及31．5％(3／8)。治疗效果明显。结论 U管引流在晚期肝门部胆管癌的应用可取得良好的治疗效果，提高病人生存质量及延长患存活期。     

肝门部胆管癌的外科治疗

肝门部胆管癌切除率很低,作者在1991年前收治17例中仅切除1例,切除率5.9%。此后,采用了附加肝叶的扩大切除,9例病人切除4例,切除率为44.4%,较前明显提高。本组无围术期死亡,存活期明显延长。作者强调B超在诊断上的重要作用。对梗阻性黄疸鉴别诊断时要充分考虑该病的可能性。主张早期手术,认为术前PTBD弊多利少。作者改进了胆肠吻合的缝合方法,避免了吻合口胆漏,同时指出提高切除率的另一关键是施术者的决心和经验。应多争取一期切除。     

Interstitial radiation therapy for carcinoma of the penis using iridium 192 wires: the Henri Mondor experience (1970-1979)

From 1970 to 1979, a group of 50 patients was treated for squamous cell carcinoma of the penis by interstitial irradiation using an afterloading technique and iridium 192 wires. The group included 9 patients with T1 tumors, 27 with T2 tumors, and 14 with T3 tumors. Forty-five patients presented with no metastatic inguinal nodes (N0), 3 patients with N1 nodes, and 2 patients had N3 nodes. After treatment, 11 patients (1 T1, 6 T2 and 4T3) developed local recurrences; 10 of these 11 patients underwent penile amputation which controlled the tumor in 7 of the patients. One patient refused amputation. Three patients developed post-therapeutic necrosis which necessitated partial amputation in 2 cases. Eight patients developed post-therapeutic urethral stenosis, which required surgical treatment in three of the cases. Overall, at their last follow-up examinations, 74% of the patients were free of disease with conservation of penile morphology and function. Most patients without metastatic nodes (37/45) at diagnosis did not receive prophylatic treatment of the groin. Two of these patients developed delayed metastatic nodes; one was successfully salvaged. All 5 patients presenting with metastatic nodes at diagnosis died, four with uncontrolled regional disease. Twenty-one percent of the patients died of their disease. We advocate interstitial irradiation using iridium 192 wires for the treatment of non-infiltrating or moderately infiltrating squamous cell carcinoma of the penis in which the largest dimension does not exceed 4 cm. Pre-implant circumcision and regular long-term follow-up are necessary. More extensive tumors are better managed surgically. When regular follow-up can be assured, it is reasonable to forgo prophylactic treatment of the inguinal nodes in patients presenting without groin metastasis.     

肝细胞肝癌和肝胆管细胞癌的超声鉴别价值

目的 探讨超声鉴别肝细胞肝癌和肝胆管细胞癌的应用价值.方法 回顾性分析经手术病理证实的肝脏恶性肿瘤98例患者,临床表现为不同程度无诱因乏力、腹胀、右上腹隐痛不适或黄疸,应用彩色多普勒超声诊断仪,观测肝内胆管走行以及门静脉有无癌栓、腹腔有无积液和淋巴结肿大等,形态、大小、位置、内部及边缘回声,肿瘤的边界及包膜,彩色血流信号显示、以及肿块及周边血流动力学改变、门静脉血流、肝动脉血流改变等特征.结果 肝细胞肝癌共77例,其诊断准确率为91％,彩色多普勒超声显示阻力指数大于0.75,肝动脉供血为主,肿块内部血供丰富;肝胆管细胞癌21例,诊断准确率为76％,超声表现为,肿块内部血供不丰富,肿块无明显边界,肝内不规则的不均匀低回声区,无包膜.肝细胞癌患者超声诊断率高于肝胆管细胞癌患者,肝细胞癌单发与多发差异并不明显,而肝胆管细胞癌主要以单发为主.肝细胞癌组合并甲胎蛋白升高、肝硬化以及HBsAg升高显著高于肝胆管细胞癌组,而肝胆管细胞癌组合并结石以及化脓性感染的比例高于肝细胞癌组,两组差异具有统计学意义(P＜0.05).结论 超声对肝细胞肝癌和肝胆管细胞癌的诊断准确率高,是诊断和鉴别诊断肝癌的重要技术.     

胆管癌中MDM2和PTEN的表达及其相关性

Abstract：Objective To investigate the expressions of MDM2 and PTEN in bile duct carcinoma(BDC),and to evaluate their possible relationship and clinical signifi cance. Methods The protein levels of MDM2and PTEN were examined by Elivision immunohistochemistry in 42 samples of BDC tissues and 22 samplesof adjacent hepatic tissues. Results The expression rate of MDM2 in BDC tissues was 38.1%, signifi cantlyhigher than that in adjacent hepatic tissues (P<0.05). Patients with low differentiation or lymph nodemetastasis had a higher tendency to express MDM2 in BDC tissues (P<0.05). The expression rate of PTENwas 31.0% in BDC tissues, signifi cantly lower than that in adjacent hepatic tissues (χ2=10.168, P<0.05). Forthe PTEN expressions in BDC tissues, no statistical signifi cance was found in clinicopathological parameters,such as tumor size, differentiation, TNM stage or lymphnode metastasis (P>0.05). The expression of MDM2was negatively correlated with that of PTEN in BDC tissues (rs=-0.313,P<0.05). Conclusion The expressionof MDM2 may be associated with the progression of BDC. It may serve as an index for prognosis of BDC.     

局部晚期胆管癌立体定向低分割放疗的疗效分析

目的 :研究立体定向放射治疗 (SRT)结合胆汁引流和 /或常规分割体外照射治疗胆管癌患者的疗效分析。方法 :5 2例胆管癌患者根据不同治疗方法分 4个组。 1 6例行胆肠内引流术加SRT ;1 3例行胆肠内引流术 ,再行常规体外照射和SRT ;1 2例单纯行SRT ;1 1例行常规体外照射加SRT。结果 :肿瘤基本消失 2 7例 ,肿瘤缩小 5 0 %以上 2 3例 ,总有效率96 2 %。 4个组患者的 1年生存率分别为 6 8 8%、6 9 2 %、5 0 0 %和 5 4 5 %。配合常规体外照射者较未行常规体外照射者 1年生存率无显著性差异 (P >0 0 5 )。所有患者的中位生存期为 1 5个月。结论 :对局部晚期胆管癌 ,进行胆肠内引流术配合立体定向放射治疗是一种有效的治疗方法     

192Ir核素脑瘤间质内照射的动物实验与病理学观察研究

目的观察用１９２Ｉｒ后装机对脑瘤行间质内照射的生物学反应与疗效。材料与方法选用Ｇ４２２皮下荷瘤小鼠模型作照射后肿瘤生长抑制试验及Ｃ６胶质母细胞瘤脑内荷瘤模型作照射后小鼠存活期延长试验，并进行病理学观察。各设２．５Ｇｙ，１０Ｇｙ及对照３个组进行。结果照射后１４天Ｇ４２２皮下肿瘤体积：对照组，２．５Ｇｙ组和１０Ｇｙ组分别为８．３４±１．９８ｃｍ３，５．７３±３．９３ｃｍ３和１．００±１．９ｃｍ３，３组间有显著差异。Ｃ６脑内荷瘤照射后其存活期明显延长，病理学证明照射后瘤组织发生各时相的凋亡与坏死。结论用１９２Ｉｒ行脑胶质瘤间质内照射是治疗脑深部肿瘤的一种可供选择的有效方法     

局部晚期胆管癌28例三维适形放射治疗(3DCRT)分析

目的 探讨3DCRT治疗胆管癌的疗效。方法 不能手术的胆管癌28例,10例胆管引流术后行3DCRT;单纯3DCRT18例,肿瘤PTV单次剂量2Gy,30～35次、6～7周完成,总剂量60～70Gy。结果 肿瘤病灶完全缓解（CR）16例（57.1%）,部分缓解（PR）8例（28.6%）,总有效率（CR＋PR）为85.7%,1年生存率为60.7%。结论 3DCRT治疗胆管癌能有效控制肿瘤,近期疗效满意,远期疗效及反应需进一步观察。     

凝集素点印迹法分析胆汁糖蛋白糖链结构诊断胆管癌

目的：研究胆管癌胆汁中的肿瘤相关糖蛋白N－连接型糖链结构及其诊断价值。方法将31例胆管癌胆汁和13例良性胆道疾病胆汁直接点在硝酸膜（NC）上，采用辣根过氧化物酶（HRP）标记的刀豆凝集素（ConA)、欧曼陀罗凝集素（DSA）、麦胚凝集素（WGA）小豆凝集素（LCA）进行点印迹分析，结果胆管癌组和良性组ConA、DSA、LCA和WGA阳性率（阳性例／总例数）分别为80．6％（25．31％）和76．95（10．13）、74．2％（23／31）和0（0／13）、70．0％（22／31）和15．4％（2／13）、80．65（25／31）和23．1％（3／13），胆管癌组DSA、LCA和WGA阳性率高于良性组（P＜0．05）。结论胆管癌胆汁糖蛋白复杂型糖链增多，其核心岩藻糖和唾液酸含量丰富，可能出现偏二天线以及天线数的增加，胆汁糖蛋白的凝集素印迹分析法为胆管癌的诊断提供了新的有效方法。     

Simultaneous Development of Gallbladder and Bile Duct Carcinomas with Atypical Epithelium Intervention: A Case Report

An 81-year-old woman, diagnosed as having a lower bile ductcarcinoma by percutaneous transhepatic cholangiography and cytologyof the bile after the onset of repeated nausea and fever aroundNovember, 1986, was given a pancreatoduodenedomy in February,1987. From histological analyses of specimens taken at surgery,papillary adenocarcinoma of the lower bile duct was revealedwith a massive amount of mucin in the cancerous gland lumens,the bile duct and the tubular adenocarcinoma retained in themucosal layers of the gallbladder. Lying between these carcinomasites was found atypical epithelia of a lesion borderline betweenbenign and malignant (Group III). The patient's postoperativeprogress was fair, but she died suddenly of cerebral hemorrhagein July, 1988. No intraperitoneal or general carcinoma relapsewas found at autopsy. This is one of the relatively rare casesof a simultaneous development of gallbladder and bile duct carcinomasand we found it of great interest that these carcinomas existedthrough an intermediate atypical epithelium.     

Intraluminal low-dose-rate 192Ir brachytherapy combined with external beam radiotherapy and biliary stenting for unresectable extrahepatic bile duct carcinoma

PURPOSE: To evaluate the results of combined-modality therapy, including external beam radiotherapy, intraluminal (192)Ir, and biliary stenting for extrahepatic bile duct carcinoma. MATERIALS AND METHODS: Between 1988 and 1998, 93 patients with unresectable extrahepatic bile duct carcinoma underwent definitive radiotherapy. The dose of external beam radiotherapy was 50 Gy in 25 fractions. Low-dose-rate (192)Ir was delivered at a dose of 27-50 Gy (mean 39.2) at 0.5 cm from the source. An expandable metallic endoprosthesis was used to establish an internal bile passage. RESULTS: The median survival was 12 months, with a 1-, 3-, and 5-year actuarial survival rate of 50%, 10%, and 4%, respectively. Tumor length, hepatic invasion, and distant metastasis significantly affected survival. Ninety-six percent of patients could successfully remove external drainage catheters. The actuarial biliary patency rate for these patients at 1, 3, and 5 years was 52%, 29%, and 18%, respectively. Tumor length, tumor diameter and T stage were significantly associated with the patency rate. Mild-to-severe gastroduodenal complications were observed in 32 patients and were significantly associated with the active length of (192)Ir and linear source activity. Eight patients had treatment-related biliary fistula. CONCLUSIONS: Our combined-modality therapy provided reasonable local control and improved the quality of life of patients with extrahepatic bile duct carcinoma. Because none of the treatment characteristics had any impact on survival or biliary patency, lower dose levels and/or a localized target volume are recommended to minimize morbidity.