经皮热消融治疗疑难部位肝肿瘤引导技术的临床应用进展

肝肿瘤热消融技术日趋成熟,已成为仅次于外科手术的常用治疗手段。邻近肝门、肝内重要管道、胆囊、膈肌和胃肠道等部位的肝肿瘤,由于操作难度大、并发症发生率高,是经皮热消融治疗的相对禁忌证。近年来随着经皮引导技术和消融设备技术的不断进步,疑难部位的肝肿瘤可以进行经皮热消融治疗,并取得可靠疗效。本文就经皮热消融治疗疑难部位肝肿瘤引导技术的临床应用进行综述。     

微波消融治疗对肝癌患者免疫功能的影响

近10多年来,随着临床中微波技术的成熟应用及配套技术的进展,微波消融已成为目前治疗肝癌的微创方法之一,与手术切除不同之处在于消融后肿瘤组织仍残留在体内。国外研究表明,微波消融治疗肝癌时热消融除可直接杀灭癌细胞外,还可刺激机体产生抗肿瘤免疫效应。但国内关于微波     

影像引导肝脏肿瘤热消融治疗技术临床规范化应用专家共识

<正>肝脏肿瘤热消融是指通过热效应原位灭活肝脏肿瘤的局部治疗方法,包括射频消融(radiofrequency ablation,RFA)、微波消融(microwave ablation,MWA)、冷冻消融(cryoablation,Cryo-A)、激光消融(laser ablation,LA)、超声消融(ultrasound ablation,UA)等。多在影像引导下经皮穿刺实施,具有操作简便、微创、精准、疗效确切等优点,也可在腹腔镜下或开放术中完成,临床应用日益广泛。肿瘤消融在我国     

肝脏实时超声造影在糖尿病并发肝癌患者微波消融治疗中的应用

目的在微波或射频消融治疗中,针对临床糖尿病并发肝癌患者采用实时超声造影的应用效果进行分析研究。方法收集2013年3月—2015年3月期间20例糖尿病并发肝癌患者的37个病灶进行采用微波或射频消融治疗的有关资料,治疗前,手术过程中及术后都实施肝脏超声造影,采用B超引导的经皮穿刺肝脏肿瘤方法对18例患者进行微波方法治疗,对2例患者进行射频消融方法治疗。结果患者都没有产生术后出血、感染及胆漏等并发症症状;对于患者肝脏肿瘤微波或射频消融后肝脏超声造影检查结果判定疗效具有90%准确率(18/20),B超CDFI检查结果的判定疗效具有77%的准确率(15/20),两组数据差异有统计学意义(P0.05)。结论在检查准确率方面,将超声造影与CT增强/核磁共振相结合用于对诊断、评价方法的补充,可获得更显著的效果。     

局部消融在肝细胞癌治疗中的应用

手术切除和肝移植被认为是肝细胞癌(HCC)根治性治疗手段,但仅有10%~20%的HCC患者能接受这些治疗。近些年来,射频消融、微波消融、冷冻消融及新近出现的不可逆电穿孔消融等局部治疗方法逐渐成为无法手术患者的替代治疗。除了局部控制肿瘤生长改善预后外,消融技术还有助于肿瘤降级以便二次切除。重点介绍了射频消融及联合其他治疗手段治疗HCC的进展,对射频消融与其他局部消融进行了比较,简述了智能导航技术在辅助消融中的应用,认为随着影像医学的发展以及其他相关领域的进步,未来消融技术在临床应用中将更加广泛。     

影像导引肝脏恶性肿瘤多模态消融治疗技术专家共识

影像导引肝脏恶性肿瘤多模态消融治疗是以医学影像技术为导引,在冷冻消融与热消融交替转换过程中,通过对病灶区温度精准控制和消融过程定量规划,彻底破坏原位肿瘤细胞及其循环系统,同时最大程度释放活性肿瘤抗原,从而达到控制肝脏恶性肿瘤复发转移的目的。为规范肝脏恶性肿瘤多模态消融治疗技术操作,便于不同层级医院开展实施,确保医疗安全和临床疗效,中国抗癌协会肿瘤介入学专业委员会和上海市抗癌协会实体肿瘤聚焦诊疗专业委员会组织国内肿瘤治疗领域的多学科专家共同参与,认真讨论,最终达成本共识。     

经皮联合开腹微波消融术治疗多发危险部位肝脏转移瘤疗效分析

目的评价经皮联合开腹消融术治疗多发危险部位肝脏转移瘤的有效性及安全性。方法在全麻下采用经皮联合开腹微波消融术治疗1例男性59岁结肠癌并发多个危险部位肝脏转移瘤患者,其危险部位病灶(0.9 cm×0.8 cm)位于肝右静脉与肝中静脉夹角处,毗邻心脏和下腔静脉,采取开腹微波消融治疗;对另2处非危险部位病灶(1.4 cm×0.9 cm和3.0 cm×2.8 cm)采取经皮微波消融治疗,观察术后并发症及肿瘤复发情况。结果该患者手术顺利,术后未出现严重并发症,消融病灶均完全坏死,随访三个月,消融部位未见肿瘤残留,未发现新病灶。结论采取经皮联合开腹消融术治疗多发危险部位肝脏肿瘤是安全有效的。     

实体肿瘤消融的免疫效应及联合免疫治疗的临床研究现状

随着医学的不断进步,消融作为一种实体肿瘤微创治疗技术,而大量应用于临床并获得较好疗效.肿瘤消融亦可对肿瘤微环境产生影响,从而为肿瘤特异性免疫识别提供一个良好的环境,而联合免疫治疗可进一步增强其抗肿瘤免疫效应,改善长期疗效.关于肿瘤消融对机体免疫功能的影响以及免疫联合治疗近年来成为研究的热点,在临床病例中的应用逐渐增加,本文重点针对实体肿瘤消融的免疫效应及联合免疫治疗的临床研究文献进行总结,分析其临床应用现状.     

肝肿瘤热消融的规范化治疗

热消融已成为同手术切除、肝移植治疗肝癌的三大根治方法,其疗效及微创性越来越受到重视。然而中国肝癌须行消融治疗的患者多数肝功能差,治疗难度大,复发率高而影响疗效及普及推广。重点简述影像指导下肝肿瘤热消融规范化治疗的原则和方案策略,旨在提高疗效及本项技术的安全性。     

较大肝癌局部消融的关键问题

近年来,超声、CT、MRI 引导下射频消融（RFA）和微波消融（MCT）作为微创热消融技术迅速发展,已证实热消融治疗肝癌安全、廉价、有效,且极具前景。对于小肝癌（〈3 cm）的疗效确切[1],目前被临床列为一线治疗方法[2]。对大于3 cm 的肝癌进行消融,虽有较高的坏死率[3],但由于受消融热场区限制,存在完全灭活困难,局部复发率高的问题[4]。鉴于在临床实际工作中,小肝癌比例较少,而3 cm 以上较大肝癌最常见,因此提高较大肝癌局部消融的疗效成为改善肝癌患者预后的关键。如何能做到穿刺次数少,又完全灭活肿瘤、减少消融治疗后肝癌的局部复发已成为重要的研究热点。     

Thermal ablative therapy for malignant liver tumors: a critical appraisal

The management of primary and secondary malignant liver tumors poses a great challenge to clinicians. Although surgical resection is the gold-standard treatment, most patients have unresectable malignant liver tumors. Over the past decade, various modalities of loco-regional therapy have gained much interest. Among them, thermal ablative therapy, including cryotherapy, microwave coagulation, interstitial laser therapy, and radiofrequency ablation (RFA), have been proven to be safe and effective. Despite the effective tumor eradication achieved within cryotherapy, the underlying freeze/thaw mechanism has resulted in serious complications that include bleeding from liver cracking and the 'cryoshock' phenomenon. Thermal ablation using microwave and laser therapy for malignant liver tumors is curative and is associated with minimal complications. However, this treatment modality is effective only for tumors <3 cm diameter. Radiofrequency ablation seems to be the most promising form of thermal ablative therapy in terms of a lower complication rate and a larger volume of ablation. However, its use is restricted by the difficulty encountered when using imaging studies to monitor the areas of ablation during and after the procedure. Moreover, the techniques of RFA need to be refined in order to achieve the same oncological radicality of malignant liver tumors as achieved by surgical resection. As each of the loco-regional therapies has its own advantages and limitations, a multidisciplinary approach using a combination of therapies will be the future trend for the management of malignant liver tumors.     

Ablation techniques for primary and metastatic liver tumors

Ablative treatment methods have emerged as safe and effective therapies for patients with primary and secondary liver tumors who are not surgical candidates at the time of diagnosis. This article reviews the current literature and describes the techniques, complications and results for radiofrequency ablation, microwave ablation, cryoablation, and irreversible electroporation.     

Mucosal Ablation in Patients with Barrett’s Esophagus: Fry or Freeze?

The management of Barrett’s esophagus and early esophageal adenocarcinoma has shifted away from esophagectomy and toward endoscopic techniques, including endoscopic resection and ablative therapies. The most commonly used ablative therapies are radiofrequency ablation and cryotherapy. Radiofrequency ablation has risen to the top of the management algorithm due to its favorable safety profile and established track record of efficacy in patients with dysplastic Barrett’s. Cryotherapy offers early promise as an alternatively safe and effective ablative modality. We review radiofrequency ablation and cryotherapy techniques, and updated data regarding their efficacy and safety as well as their roles in the management of Barrett’s esophagus.     

Laparoscopic microwave ablation of liver tumors: our experience

BACKGROUND/AIMS: Microwave ablation is the most recent development in the field of tumor ablation and is a well established and safe local ablative method available for liver tumors (both primary and secondary tumors). The technique allows for flexible approaches to treatment, including percutaneous, laparoscopic, and open surgical access. Laparoscopic technique has the advantages of accurate tumor staging, better tolerability and low cost. It can be performed in tumors which are close to the vital organs. The aim of this study was to evaluate the feasibility and safety of laparoscopic microwave ablation of liver tumors. METHODOLOGY: During January 2001 to December 2005, 57 patients with liver tumors were treated with laparoscopic microwave ablation in the department of Surgical Oncology. There were 34 male and 23 female patients. Out of 57 patients, 11 patients had hepatocellular carcinoma and 46 patients had secondaries in the liver. The most common source of secondaries was colorectal cancers. Laparoscopic microwave ablation of tumors was performed in these patients. RESULTS: During the study period, 57 patients with no evidence of extrahepatic disease underwent laparoscopic microwave ablation of unresectable hepatic tumors. No major intraoperative complications occurred. Postoperatively all the patients did well. Four patients developed liver abscess at the ablation area. Two patients required percutaneous aspiration of the liver abscess. No other major complications occurred. Follow-up CT scan shows complete necrosis of the tumors. Patients were followed-up at regular intervals. CONCLUSIONS: Laparoscopic microwave ablation is a feasible and safe alternative to open microwave ablation of the liver tumors. It carries all the advantage of minimal invasive surgery. In experienced hands, microwave ablation using laparoscopic technique can be done safely and effectively.     

Endoscopic therapy for Barrett's esophagus and early esophageal cancer:Where do we go from here?

Since Barrett's esophagus is a precancerous condition,efforts have been made for its eradication by various ablative techniques.Initially,laser ablation was attempted in non-dysplastic Barrett's esophagus and subsequently,endoscopic ablation using photodynamic therapy was used in Barrett's patients with high-grade dysplasia who were poor surgical candidates.Since then,various ablative therapies have been developed with radiofrequency ablation having the best quality of evidence.Resection of dysplastic areas only without complete removal of entire Barrett's segment is associated with high risk of developing metachronous neoplasia.Hence,the current standard of management for Barrett's esophagus includes endoscopic mucosal resection of visible abnormalities followed by ablation to eradicate remaining Barrett's epithelium.Although endoscopic therapy cannot address regional lymph node metastases,such nodal involvement is present in only 1% to 2% of patients with intramucosal adenocarcinoma in Barrett esophagus and therefore is useful in intramucosal cancers.Post ablation surveillance is recommended as recurrence of intestinal metaplasia and dysplasia have been reported.This review includes a discussion of the technique,efficacy and complication rate of currently available ablation techniques such as radiofrequency ablation,cryotherapy,argon plasma coagulation and photodynamic therapy as well as endoscopic mucosal resection.A brief discussion of the emerging technique,endoscopic submucosal dissection is also included.     

Recent advances in the treatment of colorectal liver metastases

Liver metastases are the major cause of death coloroctal resection for cancer. Colorectal liver metastases are unique because of the potential for cure. Presently surgical resection is the gold standard of treatment. Complete R0 resection gives 5-year survival of up to 24-44%. Over the years there have been extensive efforts in devising new modalities of treatment for this disease. These include methods to increase the resectability such as portal after vein emolization & two-stage surgery, py with newer drugs and methods such chronotherapy & hepatic artery infusion chemotherapy, newer methods of radiotherapy, local ablative therapies such as cryoablation, radiofequency ablation, microwave ablation & laser interstitial thermal therapy, and biological therapy. Biological therapy is largely investigational, but holds great promise for the future.     

Microwave ablation of a large renal aspergilloma

Increasing numbers of immunocompromised patients have led to a corresponding rise in the incidence of invasive Aspergillus infections. Despite advances in antifungal therapy coupled with reduction in immunosuppression, invasive aspergillosis is associated with significant morbidity and mortality. Although surgical debulking has proven effective in difficult‐to‐treat cases, patient comorbidities may prevent such intervention. Non‐invasive alternatives to surgery are needed. Microwave ablation has many advantages over other ablative techniques, including convection profile, faster heating time, and higher intra‐lesion temperatures, which may be associated with greater therapeutic efficacy. We report a case of microwave ablation as an adjunct to medical therapy in angioinvasive renal aspergilloma.     

Minimally invasive image-guided therapy of primary and metastatic pancreatic cancer

Pancreatic cancer is a challenging malignancy with limited treatment options and poor life expectancy. The only curative option is surgical resection, but only 15%-20% of patients are resectable at presentation because more than 50% of patients has distant metastasis at diagnosis and the rest of them has locally advanced pancreatic cancer (LAPC). The standard of care first line treatment for LAPC patients is chemotherapy with or without radiation therapy. Recent developments in minimally invasive ablative techniques may add to the treatment armamentarium of LAPC. There are increasing number of studies evaluating these novel ablative techniques, including radiofrequency ablation, microwave ablation, cryoablation and irreversible electroporation. Most studies which included pancreatic tumor ablation, demonstrated improved overall survival in LAPC patients. However, the exact protocols are yet to set up to which stage of the treatment algorithm ablative techniques can be added and in what kind of treatment combinations. Patients with metastatic pancreatic cancer has dismal prognosis with 5-year survival is only 3%. The most common metastatic site is the liver as 90% of pancreatic cancer patients develop liver metastasis. Chemotherapy is the primary treatment option for patients with metastatic pancreatic cancer. However, when the tumor is not responding to chemotherapy or severe drug toxicity develops, locoregional liver-directed therapies can provide an opportunity to control intrahepatic disease progression and improve survival in selected patients. During the last decade new therapeutic options arose with the advancement of minimally invasive technologies to treat pancreatic cancer patients. These new therapies have been a topic of increasing interest due to the severe prognostic implications of locally advanced and metastatic pancreatic cancer and the low comorbid risk of these procedures. This review summarizes new ablative options for patients with LAPC and percutaneous liver-directed therapies for patients with liver-dominant metastatic disease.     

Treatment for hepatocellular carcinoma in Japan over the last three decades: Our experience and published work review

Hepatocellular carcinoma (HCC) is one of the most common causes of cancer‐related mortality worldwide. In the last few decades, there has been a marked increase in therapeutic options for HCC and epidemiological characteristics at HCC diagnosis have also significantly changed. With these changes and advances in medical technology and surveillance program for detecting earlier stage HCC, survival in patients with HCC has significantly improved. Especially, patients with liver cirrhosis are at high risk of HCC development, and regular surveillance could enable early detection of HCC and curative therapy, with potentially improved clinical outcome. However, unfortunately, only 20% of HCC patients are amenable to curative therapy (liver transplantation, surgical resection or ablative therapies). Locoregional therapies such as radiofrequency ablation, percutaneous ethanol injection, microwave coagulation therapy and transcatheter arterial chemoembolization play a key role in the management of unresectable HCC. Currently, molecular‐targeted agents such as sorafenib have emerged as a promising therapy for advanced HCC. The choice of the treatment modality depends on the size of the tumor, tumor location, anatomical considerations, number of tumors present and liver function. Furthermore, new promising therapies such as gene therapy and immunotherapy for HCC have emerged. Approaches to the HCC diagnosis and adequate management for patients with HCC are improving survival. Herein, we review changes of epidemiological characteristics, prognosis and therapies for HCC and refer to current knowledge for this malignancy based on our experience of approximately 4000 HCC cases over the last three decades.