肝切除治疗巨大肝癌的体会

肝切除治疗直径１０ｃｍ以上的巨大肝癌３８例．切除的标本湿重７５０～５０００ｇ．平均１０５０ｇ。全组无手术死亡。术后１、２、３ａ生存率分别为６３％、１０．５％和５．３％．延长患者生存时间的效果是明显的．并对肝切除治疗巨大肝癌的可行性及有关问题进行了讨论。     

171例巨大肝癌手术切除治疗体会

目的 探讨肝切除巨大肝癌的安全性和可行性。方法 回顾性总结切除巨大肝癌１７例的治疗结果,对肝切除治疗巨大肝癌应注意的一些问题进行了讨论。结果 肝切除治疗巨大肝癌１７１例中的常术后１个月内死亡２例（１．２％）,术后１、２、３、５和０年生存率分别为６６．１％、４２．１％、３２．７％、１２．２％和２．３％,说明肝切除对延长巨大肝癌患者生存时间的效果是明显的。结论肝切除治疗巨大肝癌是安全可行而且有效的。     

肝癌多模式治疗的远期疗效

作者报道了过去３０年间收治的２３８８例经病理证实的原发性肝癌多模式治疗的远期疗效。手术切除（ｎ＝１６５０）后５年、１０年生存率分别为３９．３％、２９．２％，其中小肝癌（≤５ｃｍ，ｎ＝５６９）为６１．９％、４５．４％。液氮局部冷冻（ｎ＝１９１）后５年生存率为３７．９％，其中小肝癌（ｎ＝５６）为５３．１％。不能切除肝癌缩小后二期切除（ｎ＝７１）５年生存率为６６．０％。肝癌复发再切除（ｎ＝１４７）后５年生存率为３４．５％。全组生存５年以上２１４例，其中小肝癌１１３例（占５２．８％），生存１０年以上５７例。本结果表明，早期发现小肝癌、早期手术切除是可使患者获得长期生存，二期切除可能是提高不能切除肝癌疗效的重要途径，对根治性切除术后亚临床复发和转移的再手术能进一步提高疗效。     

再切除在肝癌复发治疗中的作用和地位

目的 探讨再切除在肝癌术后复发治疗中的价值。方法 回顾性分析1988～1999年30例肝癌复发再手术切除的随访资料。结果 对30例肝癌术后复发病人共行33例次手术，首次手术后1，2，3，5年总生存率分别为93．3，73．3，56．7，36．7％。第一次再手术后1，3，5年生存率分别为63．3，23．3，13．3％。肺转移切除后1，3，5年生存率分别为71．4，42．9，28．6％。结论 肝癌术后复发行再切除能显著提高病人远期生存率，是目前肝癌术后复发的首选治疗方案。     

31例肝内复发性肝癌的再切除治疗分析

目的：探讨肝内复发性肝癌的再切除治疗的价值。方法：对1980年至2000年31例肝内复发性肝癌的临床资料、手术方法及预后进行回顾性分析。结果：全组无手术死亡，术后1、3、5年生存率分别为93．5％，69．2％及50．1％，二次切除后的1、3、5年生存率分别为82．1％、32．8％及25．4％，最长一例已无瘤生存12年，而140例未再手术者的5年生存率仅9．3％，其中TACE组及PEI组的5年生存率相似，分别为12．2％及14．8％。结论：再手术切除是治疗肝内复发肝癌最有效的方法，对不能手术者，我们推荐使用PEI术。     

原发性肝癌经肝动脉栓塞化疗术后再行肝切除的临床观察

１９８７年１月至１９９２年１２月，作者共为４８例经肝动脉栓塞化疗（ＨＡＣＥ）后肿瘤缩小的肝癌患者施行了肝切除术。全组无手术死亡。术后１、２、３年生存率分别为８４．６％、５７．２％和４４．９％。已有２例生存时间超过５年。本文对原发性肝癌（ＰＨＣ）经ＨＡＣＥ后再行切除的临床意义以及ＨＡＣＥ后再作肝切除的手术时机问题进行了讨论。     

冷冻肝切除对降低肝癌术后复发的初步评价

目的探讨冷冻肝切除对降低肝癌术后复发率和提高生存率的价值。方法对84例原发性肝癌行冷冻肝切除,即对可切除肝癌,先用液氮(-196℃)冷冻,将癌块冷冻成冰球然后立即作常规根治性肝切除。术后定期随访。复发率和生存率用寿命表法统计。结果术后恢复均顺利,无手术死亡,无严重并发症。冷冻肝切除后1、3、5年生存率分别为98．7％、83．9％和64．0％。术后复发率分别为15．1％、30．1％和39．0％。结论冷冻肝切除是安全可行的,有可能降低肝癌术后复发率和提高生存率。冷冻肝切除与常规肝切除的远期疗效比较,尚需进一步观察。     

原发性肝癌综合治疗282例分析

本文报告１９８０年６月至１９９４年１０月治疗中晚期原发性肝癌２８２例，男２３８例，女４４例，年龄１７～７６岁，结节型肝癌１３０例，巨块型肝癌９２例，弥漫型肝癌６０例，其中自发性破裂大出血２１例，全部病例经Ｂ超显像，ＣＴ扫描，肝动脉造影，ＡＦＰ测定及病理组织学检查确诊。外科手术治疗９４例，其中脉叶切除３０例，半年、１年、２年、３年、５年生存率为７９．９％，５６．０％。２２．７％１３．６．和１０．０％；行肝动脉血流阻断为主的外科综合治疗６０例，半年，１年、２年生存率为７８．３％，５２．４％，１３．８％；手术探查４例，存活期均少于４个月。对不能切除的中晚期肝癌行介入栓塞治疗１８８例，半年、１年、２年、３年生存率为７３．４％，３８．８％，１９．７％和６．７％。     

肝癌切除术前风险因素的逐步回归分析

肝癌切除术前风险因素的逐步回归分析管文贤，李开宗，傅由池，窦科峰，鱼敏手术切除肿瘤在肝癌的治疗中具有举足轻重的地位［１，２］，小肝癌术后５年生存率已达６６．３０％，１０年生存率达４８．９０％，甚至可长期存活，但多数肝癌患者合并肝硬变，因此肝癌切除术可...     

原发性肝癌的现代外科治疗（附1600例报告）

１９５９年１月至１９９５年１２月，我院对１６００例原发性肝癌行外科治疗，其中行各类肝切除术７１２例（手术切除率４４．５％），肝切除术后１、３、５年生存率为８８．３％、４９．３％、３２．９％。术中肿瘤未能切除者均行外科综合治疗，术后１、３、５年生存率为５２．６％、１８．４％、６．４％。本文着重讨论肝切除在肝癌治疗中的地位，强调综合治疗的作用，并对早期诊断、二期切除及复发性肝癌再切除等问题进行了讨论。     

Improved survival in infants and children with primary malignant liver tumors

Forty-six infants and children with primary malignant liver tumors were studied. Thirty-three had hepatoblastomas, 9 hepatocellular carcinomas, and 4 had sarcomas. Thirty-eight patients underwent liver biopsy or excision of the tumor. Nineteen patients were treated between 1952 and 1971 (mean survival 5.5 months) and the remaining 19 were treated between 1972 and 1981 (mean length of survival 30 months, 2 year survival rate 53 percent). In 21 patients with an unresectable tumor, biopsy alone was performed (mean survival 7 months). Ten patients underwent primary resection of their liver tumor (mean length of survival 23 months, 2 year survival rate 37.5 percent). Seven other patients with an unresectable tumor were treated with chemotherapy alone or in combination with radiotherapy for a mean period of 6 months before second-look celiotomy was carried out. Six of these patients (all treated after 1975) had significant reduction in the size of their tumors. Mean length of survival in this group was 4 years 2 months, and the 2 year survival rate was 100 percent; at present, 5 of these patients are living without the disease 2.5 to 7 years after diagnosis. Improved techniques in liver resection and chemotherapy before second-look celiotomy is undertaken for an unresectable lesion have improved prognosis in children with a malignant liver tumor.     

放射性磷玻璃微球治疗晚期肝癌的量效关系

目的 探讨核素微球治疗晚期肝癌的量效关系。方法 对４４例不能切除的晚期肝癌施行＾３２Ｐ玻璃微球（ｐｈｏｓｐｈｏｒｕｓ－３２ ｇｌａｓｓ ｍｉｃｒｏｓｐｈｅｒｅｓ,＾３２Ｐ－ＧＭＳ）肝动脉灌注治疗,根据吸收剂量分为高、中、低三个剂量组,手术前后以各项肝功能指标及动脉血酮体比（ａｒｔｅｒｉａｌ ｂｌｏｏｄ ｋｅｔｏｎｅ ｂｏｄｙ ｒａｔｉｏ,ＡＫＢＲ）等监测肝功能,并以ＡＦＰ、ＣＴ、单光子发射型计算机     

Long-term Survival of Patients with Unresectable Colorectal Liver Metastases treated by Percutaneous Interstitial Laser Thermotherapy

In situ ablation of colorectal cancer (CRC) liver metastases is an accepted form of treatment for selected patients. It is associated with low morbidity and mortality and increases the number of patients who may benefit from therapy compared to resection alone. This study assesses the impact of interstitial laser thermotherapy (ILT) on local tumor control and long-term survival in patients with unresectable CRC liver metastases. Percutaneous ILT was performed in patients with unresectable CRC liver metastases between January 1992 and December 1999 using a bare-tip quartz fiber connected to an Nd:YAG laser source. This was prior to the routine use of a diffusing fiber for ablative therapy. Treatment was monitored with real-time ultrasonography. Tumors were considered unresectable based on their anatomic location or the extent of liver involvement. Patients with extrahepatic disease, more than five liver metastases, or tumors larger than 10 cm in diameter were excluded from this study. Local tumor control was assessed by dynamic computed tomography (CT) 6 months after therapy. Long-term follow-up was undertaken, and the impact of various factors on survival was analyzed. Eighty patients with a mean age of 63.8 years were suitable for ILT. In total, 168 liver tumors with a median diameter of 5 cm (range 1–10 cm) were so treated. There were no procedure-related deaths. The overall complication rate was 16%, with all cases managed conservatively. Bradycardia (n = 5), pneumothorax (n = 3), and persistent pyrexia (n = 3) were the most common complications. Complete tumor ablation was noted in 67% of patients assessed by CT 6 months following the initial therapy. Median follow-up was 35 months (range 4–96 months), with 10 patients alive at the end of this period. Altogether there were 67 deaths, which were related to hepatic disease in 55 cases and to extrahepatic disease in 9; they were unrelated to malignancy in 3 others. Three patients were excluded from follow-up after ILT down-staging of tumors that allowed complete surgical resection. The median disease-free survival of patients treated by ILT was 24.6 months, with a 5-year survival of 3.8%. Poor tumor differentiation and the presence of more than two hepatic metastases were associated with lower overall survival (p < 0.01). Fourteen patients treated by ILT for postoperative hepatic recurrences had the best outcome, with a median overall survival of 36.3 months and a 5-year survival of 17.2%. Percutaneous ILT is a minimally invasive, safe, effective technique that appears to improve overall survival in specific patients with unresectable CRC liver metastases, compared to the natural history of untreated disease reported in the literature.     

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??Multi-disciplinary team and conversion therapy for colorectal cancer with unresectable liver metastases??A report of 86 patients WEI-Ye*??YE Qing-hai??YU Yi-yi??et al. *Department of General Surgery, Zhongshan Hospital??Fudan University??Shanghai200032??China
Corresponding author??QIN Xin-yu??E-mail??qin.xinyu@zs-hospital.sh.cn
Abstract Objective To analyze safety and effect of the conversion therapy for initially unresectable colorectal liver metastases (CLMs) under the guidance of multi-disciplinary team (MDT). Methods The retrospective analysis was conducted for 86 patients with unresectable CLMs received MDT management and arrived conversion therapy successfully from January 2008 to December 2011 in Zhongshan Hospital of Fudan University. The perioperative and survival outcomes??prognostic factors were evaluated. Results During the mean follow-up of 41 months (24-68 months), according to the finding time of liver metastases of 86 patients??recurrence events were 73 patients??and 39 patients died. The 1 year??2 year and 3 year overall survival rate (OS) was 90.6%??75.6% and 65.1% respectively. The median OS time was ??47.5±3.1?? months. The 1 year??2 year and 3 year disease free survival rate (DFS) was 72.1%??48.8% and 31.4% respectively. The median DFS time was ??22.0±2.9?? months. The OS and DFS were no significant difference when compared 86 patients with initially unresectable CLMs successfully arrived conversion therapy with 99 patients with initial resectable CLMs??P >0.05??. The perioperative mortality rate was 1.5%??and operative complication rate was 24.4%. Tumor regression grade and early tumor shrink could predict the prognosis of CLM patients received conversion therapy. Conclusion The conversion therapy under the guidance of MDT mode is safe and effective for unresectable CLMs. The mid-term survival rate is similar with initially resectable CLMs??and long-term survival is expected.     

多学科团队模式下结直肠癌肝转移的转化性治疗（附86例报告）

目的 探索适用于初始不可切除的结直肠癌肝转移（colorectal liver metastases,CLMs）病人转化性治疗的多学科团队（MDT）模式,评价转化性治疗的安全性和有效性。方法 回顾性分析2008年1月至2011年12月复旦大学附属中山医院经过MDT诊治模式并转化性治疗成功的86例CLMs病人的临床资料,评价MDT诊治模式下转化性治疗的实施及近远期疗效,并分析预测病人预后的因素。结果 86例病人随访41.0（24～68）个月,转移灶复发73例,39例死亡。病人的1、2、3年累积总存活率（OS）分别为90.6%、75.6%、65.1%;中位生存时间为（47.5±3.1）个月。1、2、3年无疾病存活率（DFS）分别为72.1%、48.8%、31.4%,中位DFS时间（22.0±2.9）个月,与99例初始可切除性CLMs的OS和DFS相比差异无统计学意义（P >0.05）。86例病人围手术期病死率1.5%,手术并发症发生率24.4%且经过积极支持治疗后均痊愈。肿瘤缓解程度与早期肿瘤退缩对转化性治疗病人的预后有预测作用。结论 对于不可切除的CLMs,MDT指导下的转化性治疗安全、有效,转化治疗成功病人的中期生存效果与初始可切除性CLMs相似,长期生存效果值得期待。     

冷循环射频消融联合肝动脉栓塞化疗治疗不宜手术切除的肝癌

目的:总结冷循环射频消融术联合经导管肝动脉栓塞化疗术(transcatheter arterial chemoembolization,TACE)治疗不宜手术切除肝癌的效果和经验.方法:采用冷循环射频消融术联合TACE治疗手术不宜切除肝癌31例(共44个肿瘤结节).结果:肝功能指标中除术后ALT水平较术前明显升高(P<0.05)外,其他各项指标均无统计学差异(各P>0.05).术中、术后发生窦性心动过缓、高钾血症及急性胰腺炎各1例(3/29,10.3%),无手术死亡.术后CT检查显示:44个肿瘤结节中,37个病灶(占84.1%)为完全坏死,5个病灶(占11.4%)为不完全坏死,2个(占4.5%)病灶为部分坏死.随访3~28个月,术后1年肿瘤复发率为20.7%(6/29),1年生存率为89.7%(23/29).结论:冷循环射频消融联合TACE治疗不宜手术切除的肝癌是安全有效的.     

Treatment of patients with unresectable primary hepatic malignancies using hyperthermic isolated hepatic perfusion

Primary hepatocellular carcinoma is one of the most common malignancies worldwide. Isolated hepatic perfusion (IHP) is a regional treatment technique that isolates the organ to allow delivery of high-dose chemotherapy, biological agents, and hyperthermia directly to unresectable cancers confined to the liver. This study presents our experience using IHP with melphalan with or without tumor necrosis factor (TNF) to treat patients with hepatocellular carcinoma or adenocarcinoma of hepatobiliary origin. Nine patients with unresectable primary hepatic malignancies underwent a 60-minute IHP with 1.5 mg/kgmelphalan with or without 1.0 mg TNF. Four patients failed one or more previous treatment regimens, and the mean hepatic replacement by tumor was 41% (range 10% to 75%). Patients were monitored for response, toxicity, time to recurrence, and survival. Six (67%) of nine patients experienced greater than 50% regression of tumor by objective radiographic imaging and an additional patient had a 45% reduction in tumor burden. Mean time to progression was 7.7 months for those who responded to treatment. Patients who had a response to therapy had an average overall survival of 16.3 months. IHP can be performed safely and has significant antitumor activity in patients with unresectable primary hepatic malignancies. Hepatic progession continues to be the dominant factor influencing survival in this group of patients.     

Selective internal radiation therapy by yttrium-90 microspheres for hepatocellular carcinoma after renal transplantation

We report a HBsAg-positive patient who developed hepatocellular carcinoma (HCC) 7 years after cadaveric kidney transplantation. The tumor was unresectable because of coexisting cirrhosis. Selective internal radiation (SIR) therapy, a novel therapy with the technique recently perfected, was used. Yttrium-90 microspheres were given via an angiographic catheter under fluoroscopy guidance. Serum alpha-fetal protein (AFP) was normalized within 2 wk. A follow-up abdominal CT scan revealed significant necrosis of the tumor and compensatory hypertrophy of non-diseased liver. The treatment was well tolerated except for transient liver function deterioration. The patient enjoyed 15 months of symptom-free survival before she died of liver failure. Practical aspects and potential applications of SIR therapy in this group of patients are discussed.     

Radiofrequency ablation of unresectable hepatic malignancies

Since radiation and chemotherapy have little impact on survival and no prospect for cure, surgery offers the best potentially option in patients with liver tumors. However, a lot of patients with liver tumors is not resectable due to stage combined with health problems, or poor liver function reserve. In this study, our preliminary clinical reports in patients with unresectable liver tumors treatment with RFA have demonstrated radiologic evidence of tumor necrosis and complications. Multielectrode, radiofrequency probes were supplied by RITA Medical Systems (Mountain View, California). This study involved a total of 28 liver tumors in 19 patients (including 17 patients with hepatomas and 2 patients with metastases). The mean age was 68.9 years old. The size of tumor was more than 3 cm in 15 patients. The approaches to the tumor were laparoscopic in 1 patients and open surgical in 18 patients. Hepatic vascular occlusion was combined with RFA in 5 cases. The reasons for unresectable were defined as total bilirubin, ICGR 15, cardiopulmonary function and multiplicity. The efficacy of this RFA therapy was evaluated by preoperative and follow-up CT scans or tumor makers. There tumor necrosis was shown in 15 patients (78.9%). The survival rates at the time up to 12 months were 84.2% in 16 patients. The present study has demonstrated that the RFA is able to provide a safe and effective means in controlling liver tumors.     

肝移植能否用于治疗胆管癌

胆管癌包括肝内和肝外胆管癌，传统的治疗方法首选根治性手术切除，胆管癌恶性程度高，手术切除率低，病死率高，早期肝移植治疗胆管癌的效果差，多数患者术后早期复发，长期生存率较低，近年随着供体短缺问题越来越严重，一些移植中心已将胆管癌作为肝移植的禁忌证，但也有报道反对这一观点，认为结合放化疗等辅助治疗的肝移植要优于手术切除，能明显提高患者生存率。本文结合文献和我院经验，对肝移植能否用于治疗胆管癌这一有争论的问题进行简单讨论。