原发性肝癌肝移植后肿瘤复发的化疗栓塞治疗

目的 评价介入化疗栓塞在HCC肝移植后肿瘤复发治疗中的作用.方法 12例原发性HCC肝移植后肿瘤复发、且失去外科治疗机会的患者接受1次或多次TACE治疗(平均每例2.28次).通过治疗后的影像学资料判定治疗反应,并用Kaplan-Meier生存曲线计算患者生存率.结果 12例中7例(58.3%)肿瘤体积缩小≥30%.然而,在随访期间有11例(91.3%)出现了肝内或肝外新发病灶.移植后1、2、3和4年生存率分别为83.3%、57.1%、47.6%和17.9%;复发后6、12和24个月生存率分别为66.7%,50%和31.3%.结论 对于原发性HCC肝移植后肿瘤复发且失去外科切除机会的患者,介入化疗栓塞在一定程度上可以控制肿瘤生长.     

Chemoembolization of hepatocellular carcinoma in cases of isolated liver involvement]

Chemoembolization is an effective treatment for hepatocellular carcinoma, giving results equally as good as surgical therapy for T2 tumours. Survival can be prolonged and side-effects can be reduced by combining Lipiodol and Gelfoam for chemoembolization, employing a modified technique, with repeated procedures, and using appropriate follow-up treatment. The toxicity of the procedure is acceptable, but it requires supportive therapy necessitating an intense interdisciplinary co-operation.     

Percutaneous laser ablation of hepatocellular carcinoma in patients with liver cirrhosis awaiting liver transplantation

Objective

The aim of this study was to determine the effectiveness and safety of percutaneous laser ablation for the treatment of cirrhotic patients with hepatocellular carcinoma awaiting liver transplantation.

Materials and methods

The data of 9 male cirrhotic patients (mean age 50 years, range 45-60 years) with 12 biopsy proven nodules of hepatocellular carcinoma (mean diameter 2.0 cm, range 1.0-3.0 cm) treated by laser ablation before liver transplantation between June 2000 and January 2006 were retrospectively reviewed. Laser ablation was carried out by inserting 300 nm optical fibers through 21-Gauge needles (from two to four) positioned under ultrasound guidance into the target lesions. A continuous wave Neodymium:Yttrium Aluminium Garnet laser was used. Transarterial chemoembolization prior to liver transplantation was performed in two incompletely ablated tumors.

Results

No procedure-related major complications were recorded. During the waiting time to liver transplantation local tumor progression after ablation occurred in 3 nodules (25%). At histological examination of the explanted livers complete necrosis was found in 8 nodules (66.7%, all treated exclusively with laser ablation), partial necrosis >50% in 3 nodules (25%), and partial necrosis <50% in 1 nodule.

Conclusion

In patients with cirrhotic livers awaiting liver transplantation, percutaneous laser ablation is safe and effective for the management of small hepatocellular carcinoma.     

Renal dysfunction in hepatic disease: early identification with renal duplex Doppler US in patients who undergo liver transplantation.

To improve early detection of renal dysfunction in patients who undergo liver transplantation, a prospective study was performed with intrarenal duplex Doppler sonography before and after liver transplantation in 42 patients. The duplex Doppler findings were compared with multiple clinical and laboratory findings; patients were grouped on the basis of preoperative renal resistive index (RI) and serum creatinine level. The mean initial renal RI was elevated (.73 +/- .07 [standard deviation]); after transplantation, it was lower (.60 +/- .06) (P less than .001). Thirty-six patients had a normal serum creatinine level at the preoperative Doppler examination. Patients with an elevated renal RI (n = 19) had a greater chance of subsequent renal dysfunction (P less than .001), hemodialysis (P less than .01), longer stays in the intensive care unit (P less than .05), and longer hospital stays after surgery (P less than .05) than those with a normal renal RI (n = 17). In 34 patients the RI fell 10% or more after surgery and none died, whereas five of eight patients (62%) whose RI fell less than 10% died. Doppler analysis enabled identification of patients without azotemia whose course of disease before and after surgery was similar to that of patients with clinically recognized renal disease.     

Chemoembolization of liver metastasis from breast carcinoma

Chemoembolization was performed in eight patients with liver metastasis from breast carcinoma. Five of eight patients had some radiographic regression of the liver tumors, one had stable liver disease, and two had disease progression. Two of four patients with pain showed clinical improvement of their symptoms. Only one patient with radiographic response or disease stabilization subsequently had intrahepatic progression (at 3 months). Five patients developed other metastasis, particularly brain metastasis, at a mean of 4.6 months after first chemoembolization (range, 2-12 months). All patients died within 13 months of treatment, with a mean survival of 49 months from primary diagnosis, 20 months from liver metastasis diagnosis, and 6 months from first chemoembolization.     

Recurrent hepatocellular carcinoma after liver transplantation mimicking post-transplantation lymphoproliferative disorder

Approximately 5% of patients with end-stage cirrhosis undergoing orthotopic liver transplantation have occult hepatocellular carcinoma. Careful follow up is required to detect recurrent tumour, and knowledge of the patterns of recurrence may avoid diagnostic confusion with other malignancies, such as post-transplantation lymphoproliferative disorder. This case report illustrates an unusual presentation of recurrent hepatocellular carcinoma in a 56-year-old man presenting with a para-aortic soft tissue mass, thought clinically and radiologically to represent lymphoma or post-transplantation lymphoproliferative disorder. This case demonstrates that recurrent hepatocellular carcinoma can present late after transplantation as retroperitoneal lymphadenopathy, and should alert physicians and radiologists to be aware of the radiological appearances of recurrence and of the need for early biopsy to avoid diagnostic confusion with other malignancies.     

Diagnosis and staging of hepatocellular carcinoma: comparison of CT and sonography in 36 liver transplantation patients.

Radiologic studies are important in the detection of hepatocellular carcinoma and the selection of patients for partial liver resection, liver transplantation, or palliation. We retrospectively studied 36 patients with hepatocellular carcinoma who were examined with both CT and sonography before undergoing hepatic transplantation. Pathologic findings of the entire resected liver were correlated with results of imaging studies before transplantation. Parenchymal lesions were shown by sonography in 29 cases (81%) and by CT in 34 cases (94%). Although CT was more sensitive than sonography was, both CT and sonography frequently failed to depict reliably the size of tumor or the exact number of tumor nodules as determined pathologically. Pathologic findings showed vascular invasion in 19 cases (53%), whereas CT showed invasion in 11 cases (31%) and sonography showed it in only six (17%). Nodal metastasis to the porta hepatis was found in four patients; CT correctly showed two cases (three false-positive) and sonography correctly showed one case. Intrahepatic ductal dilatation was seen in eight patients on CT but was not identified on sonography. We conclude that CT is more accurate for identifying and staging hepatocellular carcinoma, but both CT and sonography frequently fail to depict the extent (size and number of lesions) of disease, especially when underlying cirrhosis is present.     

MRI findings of recurrent hepatocellular carcinoma after liver transplantation: preliminary results

Purpose

To describe the patterns of recurrence and serial magnetic resonance imaging (MRI) features of hepatocellular carcinoma (HCC) after liver transplantation.

Materials and Methods

All cases of recurrent HCC after transplantation between September 2002 and August 2009 that underwent MRI including precontrast T1, T2‐weighted images, and postgadolinium dynamic images were reviewed. On MRI we evaluated the characteristics and patterns of recurrent HCC after transplantation.

Results

A total 7 of 76 transplanted patients (four men, three women, age range, 45–63, mean 52.7 years) were included in this study. Four patients (57.1%) were identified to have a pattern of persistent local disease (PLD) near the transplanted liver, hepatorenal space, or suture site within 2.75 years (range, 2–4 years). Two patients showed recurrent HCC in the allograft alone within 5 years. One patient showed an intraperitoneal seeding (IPS) pattern which demonstrated diffuse peritoneal infiltration and thickening within 9 months. The diffuse metastatic disease (DMD) pattern was observed as a late manifestation of PLD and IPS. The most prominent volume of recurrent tumor burden was found in an extrahepatic (5 of 7 patients) compared to an intrahepatic (2 of 7 patients) location. The signal intensities and enhancement patterns did not exhibit change with disease progression.

Conclusion

We describe four patterns of recurrence of HCC following transplant. The most prominent tumor burden was located in an extrahepatic compared to an intrahepatic location. J. Magn. Reson. Imaging 2011;33:1399–1405. © 2011 Wiley‐Liss, Inc.     

晚期肝细胞癌肝移植术后的远期疗效和匹兹堡分级的预测价值

目的 观察晚期原发性肝癌肝移植术后的远期疗效,探讨匹兹堡分级的预测价值。方法 46例不符合米兰标准的晚期肝癌患者接受原位肝移植术,观察其术后的远期疗效。依据匹兹堡标准分为4组（Ⅰ组：1～2级,6例;Ⅱ组：3级,13例;Ⅲ组：4级,17例;Ⅳ组：5级,10例）,分别监测各组的远期生存情况,并进行组间比较。结果 46例患者的3年生存率为46．7％,3年的无瘤生存率为38．8％,平均生存期32．5个月,平均无瘤生存期27．7个月。Ⅰ组患者术后无死亡和肿瘤复发,Ⅳ组患者1年无瘤生存率仅12．5％,Ⅱ、Ⅲ组患者的3年无瘤生存率在40％左右,两组之间无明显差异。Ⅱ、Ⅲ组患者的最长无瘤随访时间为58个月。结论 晚期肝癌行肝脏移植术仍有相当的远期疗效。匹兹堡标准对1、2级和5级患者有较好的预测价值,尤其对较早期肝癌的鉴别优于米兰标准,但在3、4级患者的应用有一定的局限性。     

Transjugular intrahepatic portosystemic shunt in patients who have undergone liver transplantation.

PURPOSE: Transjugular intrahepatic portosystemic shunt (TIPS) placement is an accepted treatment for refractory variceal bleeding and/or ascites in end-stage liver disease and is an effective bridge to liver transplantation. The authors present their experience with TIPS in patients with a liver transplant, who subsequently developed portal hypertension. MATERIALS AND METHODS: Thirteen TIPS were placed in 12 adult patients from 6 months to 13 years after liver transplantation for variceal bleeding that failed endoscopic treatment (n = 6) and intractable ascites (n = 6). All patients were followed to either time of retransplantation or death. RESULTS: No technical difficulties were encountered in TIPS placement in any of the patients. Four of six patients treated for bleeding stopped bleeding and did not experience re-bleeding, two had functional TIPS at 3 and 36 months and two underwent retransplantation at 3 and 7 months. Two patients had recurrent bleeding within 1 week and required reintervention. In the ascites group, one is 32 months since TIPS placement with control of his ascites, two patients underwent retransplantation at 2 and 6 weeks with interval improvement in ascites. Two patients died within a week of TIPS of fulminant hepatic failure. The last patient died 1 month after TIPS subsequent to a splenectomy. CONCLUSION: In conclusion, the placement of a TIPS in a transplanted liver, in general, requires no special technical considerations compared to placement in native livers. Although this series is small, the authors believe that TIPS should be considered a treatment option in liver transplant recipients who present with refractory variceal bleeding. TIPS may have a role in the management of intractable ascites.     

Chemoembolization of the left inferior phrenic artery in patients with hepatocellular carcinoma: radiographic findings and clinical outcome

The purpose of this study was to evaluate the radiographic findings of hepatocellular carcinoma (HCC) supplied by the left inferior phrenic artery (LIPA) and the safety and efficacy of transcatheter arterial chemoembolization (TACE) of the LIPA. From September 2002 until August 2004, 11 patients with LIPA supplying HCC were identified and successfully treated with TACE of all LIPAs. LIPA collateral vessels may supply HCC, particularly when the tumors are in the left lobe of the liver in patients who have undergone previous TACE procedures. In this setting, such collateral vessels should be sought on preprocedural imaging. These LIPA collateral vessels may be safely embolized with very good clinical results.     

Radiofrequency ablation of recurrent hepatocellular carcinoma in a patient after liver transplantation: two-year follow-up

Orthotopic liver transplantation is frequently performed for patients with end-stage liver disease complicated by the development of small hepatocellular carcinomas (HCCs). Since the adaptation of the Milan criteria, the rate of posttransplantation recurrence has significantly decreased to a rate of 10%-20%. In the setting of recurrence after transplantation, survival rates are poor, with a median of 9 months. Survival can be extended with use of definitive therapies, most often surgical. The present report describes a patient with recurrent intrahepatic HCC after liver transplantation who was treated with radiofrequency ablation and has survived 24 months with normalization of alpha-fetoprotein levels and no evidence of viable tumor on imaging.