肝细胞癌合并门静脉癌栓的多层螺旋CT诊断及临床意义

目的 探讨肝细胞癌(HCC)合并门静脉癌栓(TTPV)的发生机制与多层螺旋CT(MSCT)动态增强表现的关系,评价MSCT在诊断TTPV中的优势及临床意义。方法对268例HCC患者进行肝脏MSCT动态增强检查,共发现56例TTPV,结合DSA表现综合分析。结果56例TTPV患者在MSCT动态增强扫描时均显示出门静脉内癌栓及相关的阳性征象：表现为门静脉扩张,门静脉腔内充盈缺损及“门静脉铸形”、门静脉癌栓内及其周围可见网状供血动脉、肝动脉-门静脉分流(APS)以及肝脏灌注异常等。有3例TTPV在DSA上显示不明显。结论MSCT可判断TTPV的发生机制、供血来源及血供的丰富程度、栓子的良恶性及范围、有否合并APS及分流量大小以及与周围组织结构的关系。TTPV的MSCT诊断对指导肝癌的治疗具有重要意义。     

多层CT血管成像诊断肝癌门静脉癌栓

目的 探讨多层CT血管成像(MSCTA)技术在肝细胞癌(HCC)合并门静脉癌栓(PVTT)诊断中的应用价值。方法对127例行多层螺旋CT动态增强检查的HCC患者，分别以最大密度投影法(MIP)、容积成像法(VR)和多平面重建(MPR)技术进行MSCTA成像，比较其中62例HCC合并PVTT患者横断面与CTA图像在PVTT诊断中的差异。结果MSCTA与横断面图像均能显示全部43例门脉主干和／或一级分支癌栓；横断面和CTA成像对门脉二级和三级以下分支PVTT以及长度2cm以下PVTT的显示具有显著统计学差异。结论MSCTA可明显增加门脉分支癌栓和门脉内较小癌栓的检出率，对制定治疗计划和手术方案具有重要价值。     

肝细胞癌侵犯肝内主要管道结构的螺旋CT表现

目的 探讨原发性肝细胞癌(HCC)侵犯肝内主要管道结构(门静脉、肝静脉和胆管)的多排螺旋CT(MDCT)表现特征。方法 收集68例侵犯肝内主要管道结构的HCC患者MDCT双期增强扫描资料，进行回顾性分析。着重观察和记录肝内门静脉血管、肝静脉及下腔静脉肝内段、胆道系统以及肝实质等结构在肝动脉期和门静脉期的形态学改变。结果 68例HCC中侵犯门静脉系统并继发癌栓病例47例，侵犯肝静脉及下腔静脉肝内段12例，侵犯胆管并继发胆管内癌栓者9例。肝内静脉血管受侵的直接CT征象有：①受累静脉扩张或增粗，伴管腔内软组织密度样“充盈缺损”；②静脉内癌栓在动脉期出现强化．呈现静脉的动脉化现象等。间接征象包括：①动脉-静脉瘘形成；②癌旁肝实质在动脉期出现异常强化；③门静脉海绵样变等。HCC侵犯胆管征象为：①病灶周围胆管或近端胆管扩张；②胆管腔内软组织密度结节或肿块影。结论 HCC侵犯肝内主要管道结构可出现相应的MDCT征象。MDCT增强双期扫描结合图像重建技术可以更好地评价肝内管道结构的受侵情况。     

肝细胞癌与肝内周围型胆管细胞癌的螺旋CT动态增强与病理分析

目的 分析肝细胞癌与肝内周围型胆管细胞癌的螺旋CT动态增强特征.方法 回顾性分析经手术病理证实的80例肝细胞癌和21例肝内周围型胆管细胞癌的螺旋CT动态增强特点.结果 80例肝细胞癌共116个癌灶,增强动脉期均呈明显强化.门静脉期多表现为相对低密度(97/116),其中86个瘤灶高于动脉期密度,延迟扫描116个瘤灶强化程度不同程度下降,与邻近正常肝实质相比呈相对低密度,其中73个瘤灶高于动脉期密度;116个HCC中,64个呈现马赛克征,37个呈现假包膜征.肝内周围型胆管癌增强动脉期19例呈边缘环状强化,2例无强化,门静脉期14例呈中心片状、团簇状强化,5例延迟扫描中心强化更明显.结论 螺旋CT多期增强扫描特别是肝动脉期和延迟扫描,是肝细胞癌和肝内周围型胆管细胞癌诊断和鉴别诊断的关键扫描技术,肝细胞癌和肝内周围型胆管细胞癌增强后时间密度变化及对比剂在瘤内分布的差别,能大致反映肿瘤的病理学特征,为二者的诊断和鉴别诊断提供了重要的影像学依据.     

肝细胞癌合并门静脉癌栓、继发门静脉海绵样变多层螺旋CT表现

目的探讨肝细胞癌合并门静脉癌栓、继发门静脉海绵样变的多层螺旋CT表现。方法收集31例经病理证实为肝细胞癌合并门脉癌栓继发门静脉海绵样变的多层螺旋CT资料,与手术病理相对照,回顾分析其栓塞部位、CT表现及侧支循环开放情况。结果栓塞部位：门静脉主干及左、右支栓塞23例,其中4例合并肠系膜上静脉和（或）脾静脉、下腔静脉栓塞,1例合并胆囊浸润;门静脉主干及左支栓塞1例;f1静脉主干及右支栓塞5例,其中2例合并肝右静脉和（或）下腔静脉栓塞;门静脉主干及肠系膜上静脉栓塞1例;单纯右支栓塞1例。CT表现：平扫癌栓均为等密度;增强扫描动脉期明显不均匀强化,门静脉期强化程度减退呈等密度,相应血管内可见充盈缺损。侧支循环开放与血管扩张情况：肝门胆管周围侧支开放31例（100％）,胆囊窝周围侧支开放19例（61．29％）,胃底、胃小弯区侧支开放21例（67．74％）,食管下段侧支开放7例（22．58％）,脾静脉扩张15例（48．38％）。结论HCC并门静脉癌栓继发门静脉海绵样变的多排螺旋CT表现具有一定的特征性,可为I临床提供准确的参考信息,有助于该病的诊断。     

多排螺旋CT血管成像技术对门静脉海绵样变性侧支血管的显示

目的 探讨肝细胞癌门静脉癌栓所致门静脉海绵样变性(cavernous transformation of the portalvein．CTPV)侧支血管的多排螺旋CT血管成像显示技术。方法 18例肝细胞癌门静脉癌栓所致CTPV患者。注入造影剂后行门脉期增强扫描，采用薄层图像重建后再行二维和三维血管成像．包括最大强度投影法(MIP)、表面遮盖法(SSD)及容积再现技术(VRT)。结果 MIP法血管成像能准确显示门静脉癌栓和CTPV侧支血管的情况．包括门静脉胆支(胆囊静脉、胆管周围静脉丛)和胃支(胃左、右静脉)等，而VRT效果较差，SSD效果最差。结论 采用MIP法重建的多排螺旋CT门静脉血管成像是显示门静脉癌栓和CTPV侧支血管的较好方法。     

多层螺旋CT在肝癌合并门静脉癌栓中的临床应用价值

目的 探讨肝癌合并门静脉癌栓的多层螺旋CT（MSCT）成像表现及其诊断价值。方法 回顾性分析35例经手术病理或临床综合诊断的肝癌合并门脉癌栓的MSCT增强扫描与图像后处理技术的影像学表现,图像重建方法包括多平面重建（MPR）、最大密度投影（MIP）和容积再现（VR）3种方式。结果 PVTT直接征象：门静脉腔内条形、树枝状及结节、肿块状的低密度充盈缺损区,动脉期门脉走行区线条样异常强化或迂曲成簇扩张滋养血管影,21例门静脉主干明显增宽。间接征象：肝实质灌注异常7例,门静脉海绵样变4例,表现为门静脉旁、肝内及胆囊窝增粗迂曲成团血管影,肝动脉-门静脉分流2例,24例瘤内显示异常粗大血管影,肝外异位供血动脉2例。结论 MSCT能够显示门静脉癌栓的准确部位和门静脉血流状况,可为临床手术、介入治疗及肝移植等提供更多重要信息。     

多层螺旋CT门静脉成像在临床中的应用

目的 探讨多层螺旋CT门静脉成像的临床应用价值.方法 应用GE Light SpeedQX/i4 CT机对137例行CT增强扫描者的CT图像进行门静脉成像,并分析其结果.137例中,肝癌46例,肝硬变20例,肝海绵状血管瘤21例,肝脓肿9例,胆囊癌6例,胆管癌14例,胰腺癌16例,正常5例.结果 门静脉期成功显示门静脉、肠系膜上静脉及脾静脉者109例,其中容积再现图像显示清晰者84例,最大密度投影及多平面重建图像显示清晰者109例.显示门静脉高压45例,侧支循环开放18例,门静脉癌栓15例,单独脾静脉癌栓1例,巨大海绵状血管瘤6例.结论 多层螺旋CT门静脉成像能较清楚地显示门静脉解剖及其病变,为临床医生制定正确的治疗方案提供依据.     

壶腹癌的多层螺旋CT表现

目的：探讨壶腹癌的多层螺旋CT表现。方法：回顾分析27例经手术病理证实壶腹癌的CT平扫及动态增强扫描的影像学特点,并结合曲面重组图像分析扩张的肝外胆管及胰管的形态改变。结果：27例均发现肿瘤,并均有不同程度的胆道低位梗阻,动态增强扫描呈轻-中度强化,27例均能清晰显示肿瘤的部位、大小以及与周围组织结构的关系。结论：多层螺旋CT薄层增强扫描与曲面重组技术对壶腹癌的诊断和鉴别诊断有很大价值,并对手术治疗提供重要的指导作用。     

肝动脉-门静脉瘘的多层螺旋CT诊断

目的探讨肝动脉-门静脉分流(APS)的多层螺旋CT(MSCT)动态增强表现、诊断能力、形成机制及临床意义。方法1 100例患者进行了肝脏MSCT动态增强检查,发现80例APS,其中,肝细胞癌(HCC)71例,转移性肿瘤2例,单纯性肝硬化6例,1例无明显肝实质异常。71例HCC均经DSA检查,以DSA诊断APS为标准,对照分析MSCT诊断APS的能力及APS的CT特征。结果71例HCC在MSCT增强动脉期均发现与APS相关的阳性征象。MSCT增强表现分为:中央型(52例)和周围型(19例)。中央型表现为:①肝动脉期门静脉主干和/或左右第1级分支提早显影;②肝动脉期低密度门静脉瘤栓内及其周围有网状动脉显影(滋养动脉);③肝动脉期可见门静脉管壁强化与低密度门静脉瘤栓形成“门静脉铸型”。周围型表现为:①肝动脉期肿瘤所在肝叶的非癌变肝实质、肿瘤外周和肝叶边缘出现楔形或片状强化区,门静脉期该区域密度与其他部位正常肝组织密度一致;②肝动脉期门静脉分支呈线条状显影且与肝动脉伴行,即“轨道征”;③肝动脉期肿瘤内门静脉提早显影。结论MSCT诊断APS的准确性可与DSA相比。MSCT血管成像可望替代DSA。APS的MSCT诊断对指导肝癌的治疗具有重要意义。     

原发性肝癌合并门静脉癌栓86例治疗体会

目的探讨肝癌合并门静脉癌栓(PVTT)的有效治疗方法。方法 86例肝癌合并门静脉癌栓患者行肝切除+门静脉取栓+肝动脉、门静脉双灌注化疗栓塞及生物靶向治疗。结果 1年生存率为90%,2年生存率为85%,3年生存率为35%;结论肝切除+门静脉取癌栓+肝动脉、门静脉双灌注化疗栓塞+生物靶向治疗是治疗肝癌合并门静脉癌栓的有效治疗方法。     

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目的：评价放射介入栓塞化疗对肝癌合并门静脉癌栓的疗效。对影响疗效的多种因素进行分析。方法：219例肝癌并门静脉癌栓病人行介入治疗，18例单纯肝动脉化疗药物灌注（A组），124例肝动脉碘油栓塞加化疗灌注（B组），77例肝动脉化疗灌注加碘油栓塞加明胶海绵颗粒栓塞（C组）。结果：影响肝癌合并癌栓介入治疗疗效及生存期的因素包括肝功能Child分级、肿瘤类型大小、癌栓部位、有无合并动脉门静脉瘘及动脉静脉瘘、治疗方法、 治疗次数以及治疗后癌栓的碘油聚集情况。三种治疗方法中以C组疗效最好，B组次之，A组最差。结论：肝癌合并癌栓病人的介入疗效与多种因素密切相关，积极有针对性地选择肝动脉化疗灌注加碘油加明胶海绵栓塞有助于提高病人的生存率。     

原发性肝癌切除术后早期复发高危因素分析

目的 探讨影响原发性肝癌根治性切除术后早期复发的高危因素。方法 回顾性分析2000年6月至2002年12月广西医科大学第一附属医院经根治性手术切除的145例原发性肝癌的临床病理资料,选择16项临床、病理和治疗等指标分析其对早期复发的影响。结果 全组1年内早期复发57例,早期复发组的1年存活率为36.8％,3年存活率为3.5％,而对照组（1年后复发或随访期间无复发）1年和3年存活率分别为100％和63.6%,两组存活率差异有统计学意义（χ2=139.9, P<0.001）。单因素分析表明,年龄、肝硬化、肿瘤直径、多发肿瘤、肿瘤包膜形成、肿瘤包膜浸润、门静脉癌栓、肝静脉癌栓、微血管浸润和肿瘤Edmond-Steiner分级是影响肝癌早期复发的高危因素。多因素分析提示,肿瘤直径、门静脉癌栓、肿瘤微血管浸润和肿瘤包膜浸润是影响肝癌早期复发的独立因素。结论 术后复发是肝癌的一大生物学特性,肿瘤直径、门静脉癌栓、微血管浸润和肿瘤包膜浸润是影响肝癌早期复发的最主要危险因素。甄别肝癌切除术后早期复发的高危因素对于手术适应证的把握和术后的辅助治疗有指导性意义。     

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??Analysis of risk factors for early recurrence of primary hepatocellular carcinoma after radical hepatectomy HUANG Jin-qiu*, PENG Min-hao, ZOU Quan-qing, et al. *Department of Hepatobiliary Pancreatic Surgery, Nanhua Hospital Attached to University of South China, Hengyang421002,China Corresponding author: PENG Min-hao, E-mail: minhaopeng@yahoo.com.cn Abstract Objective To explore the risk factors for early recurrence of primary hepatocellular carcinoma after radical hepatectomy. Methods The clinical data of 145 cases of hepatocellular carcinoma performed radical hepatectomy from June 2000 to December 2002 at the First Affiliated Hospital of Guangxi Medical University were analyzed retrospectively. Sixteen factors involved in clinic, pathology and treatment were analyzed to determine their impact upon early recurrence of hepatocellular carcinoma. Results Fifty-seven cases underwent early recurrence within one year after hepatectomy. The survival rate of 1 and 3 years in early recurrence group was 36.8% and 3.5%, respectively. The survival rate of 1 and 3 years in control group (relapse one year after hepatectomy or relapse-free during follow-up) was 100% and 63.6%, respectively. The significant difference of survival rate exist between the two groups (χ2=139.9, P<0.001).The univariate analysis showed that age, liver cirrhosis, tumor diameter, multiple tumor, tumor capsule formation, tumor capsule invasion, portal vein tumor thrombus, hepatic vein tumor thrombus, microvessel invasion and tumor Edmond-Steiner grade were high risk factors for early recurrence of hepatocellular carcinoma after hepatectomy. Meanwhile, multivariate analysis indicated that tumor diameter, portal vein tumor thrombus, microvessel invasion and tumor capsule invasion were independent factors for early recurrence. Conclusion Recurrence after hepatectomy is one of main biology properties of hepatocellular carcinoma. Tumor diameter, portal vein tumor thrombus, microvessel invasion and tumor capsule invasion are main high risk factors for early recurrence. Identifing the high risk factors associated with early recurrence contributes to the grasp of operation indication and guidance of adjunctive therapy.     

Transplantation After Successful Downstaging by Multimodal Treatments of American Joint Committee on Cancer Stage IIIB Hepatocellular Carcinoma With Portal Vein Thrombi: A Case Report

The effective treatment for hepatocellular carcinoma (HCC) with American Joint Committee on Cancer stage IIIB remains controversial and challenging because of the high recurrence rate after resection and low survival rate. The median survival of those with macroscopic portal vein tumor thrombus (PVTT) is short. We reported such a case which received liver transplantation (LT) after successful consecutive downstaging therapies. A 40-year-old man with alcohol related liver cirrhosis and repeated esophageal varices bleeding had HCC with tumor thrombi in right main portal vein and the second portal branch of segment VI (stage IIIB). The received percutaneous alcohol injection, radiofrequency ablation, 8 sessions of transcatheter hepatic arterial chemoembolization, radiotherapy, and target therapy with sorafenib. Computed tomography (CT) scan and magnetic resonance imaging after treatments showed no viable fragments in the tumor and revealed both the right main portal vein and V1 branch were patent. One month later, the patient received a deceased LT. The perioperative course was rather smooth. After discharge, the interval follow-up CT studies of the chest and liver and whole body bone scan showed no tumor recurrence or metastasis up to 20 months postoperation.     

原发性肝癌合并门静脉癌栓的超声介入治疗

目的观察超声介入治疗原发性肝癌合并门静脉癌栓的疗效。方法采用B超普通探头引导下经皮肝穿刺瘤内注射无水酒精,选择性门静脉内注射药物治疗原发性肝癌合并门静脉癌栓60例。结果60例患者经上述方法治疗后,不同直径的肿瘤〈3 cm,3-5 cm和〉5 cm其肿瘤缩小率分别为：70.6%,63%和20%;38例（63.3%）患者癌栓缩小或消失。结论超声介入是治疗原发性肝癌合并门静脉癌栓的一种较为有效的手段,该方法操作简单,安全,无严重并发症。     

Clinical significance of serum cytokeratin-19 fragment (CYFRA 21-1) in hepatocellular carcinoma

Background/Purpose CYFRA 21-1, a soluble fragment of cytokeratin 19, is increased in serum in some patients with hepatocellular carcinoma, but the clinical significance of this increase is still unknown. Methods Serum concentrations of CYFRA 21-1 were measured in 240 patients with hepatocellular carcinoma prior to hepatic resection. The relationships between serum CYFRA 21-1 concentrations and clinicopathologic features were analyzed. Results The sensitivity of CYFRA 21-1 as a test for hepatocellular carcinoma was 18.8%. Serum CYFRA 21-1 was significantly higher in patients with portal vein tumor thrombus, and serum CYFRA 21-1 increased with the progression of portal vein tumor thrombus. Tumor size was related to serum CYFRA 21-1, but there were no significant correlations between serum CYFRA 21-1 concentrations and tumor differentiation or number of tumors. Although patients with stage IV tumor had significantly higher CYFRA 21-1 concentrations than those with stages I, II, and III, CYFRA 21-1 was not associated with postoperative prognosis. Conclusions Although high concentrations of CYFRA 21-1 were often detected in patients with a tumor diameter greater than 5 cm or tumor thrombus in the major portal vein, CYFRA 21-1 is not a useful diagnostic tool for hepatocellular carcinoma because of its low sensitivity.     

64排螺旋CT诊断肝癌临床价值研究

目的研究64排螺旋CT三维重建影像技术在肝癌外科中的临床应用价值。方法对2005年11月至2006年7月,南方医科大学珠江医院行64排螺旋CT三维成像检查34例原发性肝癌临床资料进行总结,并与术中探查结果、手术方式及介入治疗进行对照评价。结果34例原发性肝癌病人64排螺旋CT三维重建成像显示:癌肿肿瘤未侵犯邻近组织、血管者23例,肿瘤压迫邻近血管者9例,动静脉瘘1例,门静脉癌栓1例。3例病人行TACE(经导管肝动脉化疗栓塞术)治疗,其余31例均行手术治疗,与术中探查结果相一致者30例,正确率96.7%。行根治性切除12例,右半肝切除8例,左外叶切除5例,左半肝切除2例,左半肝切除加门静脉癌栓取栓1例,左三叶切除1例,右三叶切除1例,尾状叶切除1例。结论64排螺旋CT三维成像检查可以很好地显示肿瘤的界限、累及范围,特别能精确判断肿瘤与肝脏血管的关系,充分了解肝脏血管变异情况,其结果对病变程度估计及指导外科治疗抉择有重要价值。     

Surgical results for hepatocellular carcinoma with macroscopic portal vein tumor thrombosis

Background: The longterm results after liver resection for hepatocellular carcinoma with macroscopic tumor thrombus of the portal vein are unclear.

Study Design: The records of 47 HCC patients with tumor thrombus in the segmental portal branch (n = 33) and the first portal branch or portal vein trunk (n = 14) were reviewed in this study. Survival rates of the patients were calculated with regard to 14 clinicopathologic variables. A log-rank analysis was performed to identify which variables predicted the prognosis.

Results: Overall 1-, 3-, and 5-year survival rates were 53.9%, 33.2%, and 23.9%, respectively. The indicators of a favorable prognosis included curative liver resection, tumor size less than 10 cm in diameter, and absence of intrahepatic metastases.

Conclusions: Liver resection should be considered a therapeutic option for hepatocellular carcinoma with macroscopic portal vein tumor thrombus when the tumor is small and curative liver resection can be expected.