门静脉支架同步125I粒子条植入联合经导管动脉化疗栓塞术治疗肝癌伴门静脉癌栓

目的 探讨门静脉支架同步¹²⁵I粒子条植入联合TACE治疗肝癌伴门静脉癌栓的临床效果。方法 对15例肝癌伴门静脉癌栓患者先行经皮肝穿刺门静脉支架同步¹²⁵I粒子条植入术,再行TACE治疗,随访并计算其累积生存率和支架通畅率。结果 对所有患者均成功植入门静脉支架及¹²⁵I粒子条,未出现穿刺道出血、胆汁瘘及急性肝肾衰减等严重并发症。对全部患者共行38次TACE治疗。术后随访6~12个月,3例存活,12例死亡,其中4例死于消化道出血,2例死于肺转移,6例死于肿瘤进展致肝衰减。术后3、6、9、12个月累积生存率和支架通畅率分别为100%、60.0%、46.7%、20.0%和100%、73.3%、40.0%、20.0%。结论 采用门静脉支架同步¹²⁵I粒子条植入联合TACE治疗肝癌合并门静脉癌栓安全、可行。     

肝细胞肝癌门静脉癌栓介入分型及其临床应用价值

目的:探讨适合指导介入治疗的肝细胞肝癌门静脉癌栓介入分型。方法:根据肝细胞肝癌合并门静脉癌栓患者的动态增强CT或MR影像学表现,将门静脉癌栓分为Ⅰ~Ⅴ共5型,包括Ⅰ型、Ⅱa型/Ⅱb型、Ⅲa型/Ⅲb型/Ⅲc型、Ⅳa型/Ⅳb型、Ⅴ型,其中将Ⅰ~Ⅳ型同时合并肝动脉门静脉瘘归为Ⅴ型。观察不同分型患者经肝动脉化疗栓塞(transcatheter arterial chemoembolization,TACE)联合门静脉支架+放射性碘-125粒子条植入治疗的效果。结果:117例入选患者介入分型为Ⅰ型占10.2%(12/117)、Ⅱ型占17.1%(20/117)、Ⅲ型占53%(62/117)、Ⅳ型占19.6%(23/117)、Ⅴ型占16.2%(19/117)。所有患者均接受介入治疗,术后即刻造影显示,68例(93.1%)患者门静脉灌注明显改善。术后1~3个月增强MR/CT随访显示,植入碘-125粒子部位的癌栓均较术前明显萎缩,有效控制。结论:肝细胞肝癌合并门静脉癌栓的介入分型有助于指导临床制定个体化的介入治疗策略,使患者获益,值得临床推广。     

肝动脉化疗栓塞、射频消融联合125I粒子植入序贯治疗不可切除原发性肝癌疗效观察

[目的]探讨肝动脉化疗栓塞(TACE)、射频消融(RFA)联合125I粒子植入序贯治疗不可切除的原发性肝细胞肝癌(HCC)的临床疗效.[方法]收集2014年3月至2016年2月收治20例不可切除HCC患者(共32个癌灶,病灶大小3～12 cm).所有癌灶先进行TACE,1周后在CT引导下进行RFA,再过1周后在CT引导下进行125I粒子植入治疗,1125I粒子植入采用术前TPS计划、术中CT引导下同轴法进行,粒子植入处方剂量(PD)为80～100 Gy,术后即时或1周内CT检查传入TPS验证粒子植入质量.随访观察患者临床症状、甲胎蛋白(AFP)、肝功能、影像学(肿瘤体积)等改变情况以及临床疗效、肿瘤复发情况和相关并发症.[结果]20例患者治疗后临床症状均有明显缓解;AFP均有明显下降,与治疗前比较差异有统计学意义(P＜0.05);ALT、TBIL、ALB均降低,但与术前比较差异无统计学意义(P＞0.05);影像检查见:肿瘤片状坏死、有不同程度的碘油沉积、肿瘤体积较治疗前明显缩小(P＜0.05),增强后无明显强化;125I粒子植入术后即时TPS验证结果:技术成功率为100％,即粒子植入质量很好,ID90 ＞MPD,1例CI=1,植入粒子剂量的不均匀度＜20％PD.随访时间3～24个月(平均12.7个月),全组肿瘤完全坏死率为93.75％(30/32),中位生存时间为11.2个月,半年和1年生存率分别为95％和75％.未出现严重并发症.[结论]TACE、RFA联合125I子植入序贯治疗不可手术切除HCC,近期疗效明显,有望成为不可手术切除原发性HCC更有效的新的治疗模式.     

TACE在原发性肝癌伴门静脉癌栓术后治疗中的作用

目的 :研究TACE在原发性肝癌伴门静脉癌栓术后治疗中的作用及影响其疗效的因素。方法 :随访 4 0例原发性肝癌伴门静脉癌栓术后病人 ,其中 2 1例病人术后行TACE治疗。比较两组病人的肿瘤复发时间和生存期。单因素和多因素分析影响术后TACE疗效的因素。结果 :原发性肝癌伴门静脉癌栓单纯手术切除病人的肿瘤平均复发时间 6 .1个月 ,中位生存时间10 .3个月 ,其半年、1、2、3年生存率分别为 4 5 .9%、4 .2 %、0 %、0 %。术后行TACE的病人肿瘤平均复发时间 11.1个月 ,中位生存时间 2 0 .7个月 ,其半年、1、2、3年生存率分别为 6 2 .2 %、5 6 .3%、35 .6 %、2 8.5 % ,明显高于单纯手术病人 (P <0 .0 5 )。单因素分析提示肿瘤大小、细胞分化、化疗栓塞次数是影响术后TACE疗效的主要因素。多因素分析提示细胞分化、化疗栓塞次数影响术后TACE的疗效。结论 :TACE推迟原发性肝癌伴门静脉癌栓术后的肿瘤复发时间 ,延长病人的生存期。肿瘤细胞分化 ,化疗栓塞次数是影响术后TACE疗效的主要因素。     

门静脉支架联合~(125)Ⅰ粒子条加化疗栓塞治疗肝癌伴门静脉癌栓26例护理

总结26例肝癌伴门静脉癌栓患者行门静脉支架联合~(125)Ⅰ粒子条植入加肝动脉灌注化疗栓塞的护理。护理措施是治疗前加强与患者及家属的沟通,做好患者心理护理和进行屏气训练,治疗中做好疼痛护理和粒子核对,加强健康宣教,做好医护人员和患者及家属的辐射管理。26例患者均完成介入治疗,治疗后无严重并发症发生,患者顺利出院。     

1例肝癌病人行125I粒子条联合门静脉支架及栓塞化疗治疗的护理

肝癌合并门静脉癌栓的发生率达30%～60.2%[1],门静脉癌栓加速对肝脏的破坏,导致门静脉高压,继而出现食管胃底静脉曲张出血、肝功能衰竭、肝肾综合征等,严重影响肝癌病人的预后。经皮穿刺门静脉支架植入可降低门静脉压力,改善肝脏血液供应,保护肝功能,放射性粒子能减少支架再阻塞的几率[1]。2012年3月我科收治1例肝癌合并门静脉癌栓的病人,     

门静脉癌栓分型在肝癌经皮肝动脉栓塞化疗术治疗中的意义

目的 探讨不同门静脉癌栓分型在肝癌经皮肝动脉栓塞化疗术（TACE）治疗中的意义和疗效。方法 269例肝癌伴门静脉癌栓患者分为TACE组（217例）和对照组（52例）。比较不同癌栓分型的治疗效果和预后情况。结果 TACE治疗对Ⅰ型癌栓治疗效果明显，Ⅱ型、Ⅲ型有效，Ⅳ型无效。TACE治疗可延长肝癌伴门静脉癌栓患者生存期（P〈0．01），门脉癌栓分型程度与患者预后呈负相关。结论 Ⅰ～Ⅲ型适宜TACE治疗．Ⅳ型不宜行TACE治疗。门脉癌栓分型是决定患者治疗效果和预后的重要因素，对评价肝癌TACE治疗疗效和患者预后有指导意义。     

肝细胞癌伴门静脉癌栓的治疗进展

肝细胞癌（Hepatocellular carcinoma HCC）晚期患者60％～90％伴门静脉癌栓（portal vein tumor thrombus PVTT）形成，门静脉癌栓是导致肝细胞癌肝内播散、远处转移、肝功能恶化及术后复发的最重要因素之一，因此开展对门静脉癌栓的研究将对肝细胞癌的有效治疗、提高肝细胞癌患者的生存率和生活质量具有重要意义。目前对HCC伴PVTT的治疗方法较多，下面就其各种最新治疗进展作一综述。     

经肝动脉化疗栓塞联合门静脉碘125粒子植入治疗肝癌合并门静脉癌栓的近远期效果

【目的】探讨经肝动脉化疗栓塞(TACE)联合门赫脉碘125(^(125)I)粒子植入治疗肝癌合并门静脉癌栓(PVTT)的近远期效果及安全性。【方法】在本院接受治疗的90例肝癌合并PVTT的患者随机分为对照组和观察组,对照组采用TACE治疗,观察组采用TACE联合门静脉^(125)I粒子植入治疗。比较两组治疗前后血清学指标,治疗后复发率、生存率、无进展生存时间(PFS)、总生存期(OS)。比较两组肝脏原发肿瘤、PVTT的近期疗效以及治疗期间不良反应发生率。【结果】(1)观察组的原发肿瘤缓解率、PVTT缓解率均高于对照组,且差异均有显著性(P均<0.05)。(2)治疗后观察组患者的血清甲胎蛋白(AFP)、癌胚抗原(CEA)测定值均低于对照组,血清丙氨酸氨基转移酶(ALT)、天冬氨酸氨基转移酶(AST)、总胆红素(TBIL)水平均高于对照组(P均<0.05)。(3)观察组1年的复发率低于对照组(22.2%vs 28.9%,P<0.05),1、2、3年累积生存率均高于对照组[分别为73.3%vs 57.8%、44.4%vs 24.4%.33.3%vs 15.6%,(P均<0.05)]。观察组平均PFS,平均OS均长于对照组(P均<0.05)。(4)治疗期间两组不良反应发生率相比较差异无显著性(P>0.05)。【结论】TACE联合门静脉粒子植入治疗肝癌合并PVTT的疗效确切,可有效控制原发肿瘤和PVTT进展,延长患者生存时间,提高生存率,且安全性较好。     

高强度聚焦超声联合肝动脉化疗栓塞治疗门静脉癌栓的临床研究

目的 探讨高强度聚焦超声（HIFU）联合肝动脉化疗栓塞（TACE）治疗门静脉癌栓（PVTT）的安全性和有效性。方法将42例原发性肝癌（HCC）合并门静脉癌栓（PVTT）患者分为两组,A组（22例）采用HIFU联合TACE进行治疗,B组（20例）单纯采用TACE治疗。结果HIFU联合TACE组治疗后PVTT有5例消失,12例缩小,比TACE组疗效明显（P〈0．05）。HIFU联合TACE组,有11例患者恢复门静脉血流,癌栓内血供较单纯TACE治疗组明显减少（P〈0．05）。联合治疗组中位生存期13．8个月,较同期TACE组中位生存期7．9个月明显延长（P〈0．05）。结论HIFU联合TACE治疗PVTT是一种新的安全、有效、微创的治疗方法,能明显提高患者生活质量,延长寿命。     

Apatinib Combined With Transarterial Chemoembolization in Patients With Hepatocellular Carcinoma and Portal Vein Tumor Thrombus: A Multicenter Retrospective Study

PurposeStudies focusing on the effects of combined transcatheter arterial chemoembolization (TACE) + the tyrosine kinase inhibitor apatinib in the treatment of patients with hepatocellular carcinoma (HCC), with the location and extent of portal vein tumor thrombus (PVTT) assessed as the main variable, are rare. This multicenter, retrospective, controlled study was performed to compare the efficacy and tolerability of TACE + apatinib and TACE alone in patients with HCC and PVTT.MethodsWe retrospectively analyzed data from patients with nonresectable HCC and PVTT who underwent treatment with TACE + apatinib or TACE alone between January 2015 and January 2016. Outcomes in patients who underwent TACE + apatinib were compared with the outcomes of patients who underwent TACE alone, by using the Kaplan–Meier method, according to PVTT type: PVTT in the main portal vein (type A), PVTT in the first-order portal vein branch (type B), and PVTT in second- or lower-order portal vein branches (type C).FindingsOne hundred eighty-eight patients were included in the analysis; 85 underwent treatment with TACE + apatinib and 103 underwent treatment with TACE. TACE + apatinib was associated with a significantly greater median survival compared with TACE alone in patients with PVTT type B (12.2 vs 7.5 months; P < 0.001) or type C (13.7 vs 7.2 months; P = 0.006). Along with treatment strategies and α-fetoprotein, the absence of main PVTT was an independent factor predictive of survival on uni- and multivariate analysis. Apatinib-related grade 3 adverse events occurred in 27 patients (31.8%).ImplicationsTACE + apatinib can be of potential benefit to patients with advanced HCC with tumor thrombus in the first- and lower-order portal vein branches. Adverse events with apatinib need to be monitored during application, despite the manageable appearance.     

肝动脉化疗栓塞治疗肝癌合并门脉癌栓患者的生存分析

目的：对接受动脉化疗栓塞术（TACE）治疗的伴门脉癌栓（PVTT）的原发性肝细胞癌（HCC）的潜在预后因子进行研究,并且对比TACE治疗首发癌栓及迟发癌栓肝癌患者的生存分析.方法：回顾性分析2007年1月-2013年3月临床资料完整、伴有PVTT并接受TACE治疗的HCC患者57例,建立病例资料数据库,TACE治疗后局部肿瘤的反应通过mRECIST标准评估.应用寿命表法计算生存期.对相关因素采用Kaplan-Meier检验进行生存率的单因素分析以及COX风险比例模型进行多因素分析,筛选出独立预后因素.结果：根据mRECIST标准完全反应者（CR）1例（1.5％）,部分反应者（PR）14例（24.5％）,稳定者（SD）20例（35.5％）,进展者（PD）22例（38.5％）.6、12、18、24月的生存率分别为50.8％、29.8％、24.6％、10.5％,中位生存时间为6.8月.在多因素分析中,谷草转氨酶、胆碱酯酶、动静脉瘘、门脉主干闭塞、局部肿瘤反应均为影响患者的预后因素.结论：多个影响因素都会对PVTT的HCC患者生存时间造成影响,TACE治疗首发癌栓及迟发癌栓肝癌患者的生存率无差别.     

Biliary stent combined with iodine-125 seed strand implantation in malignant obstructive jaundice

BACKGROUNDMalignant obstructive jaundice is mainly caused by cholangiocarcinoma. Only a few patients are indicated for surgical resection, and the 3-year survival rate is < 50%. For patients who are not eligible for surgery, biliary stent placement can relieve biliary obstruction and improve liver function and quality of life. However, restenosis after biliary stents has a poor prognosis and is a clinical challenge. Biliary stent combined with iodine-125 (¹²⁵I) seed implantation can prolong stent patency and improve survival.AIMTo evaluate the safety and efficacy of biliary stent combined with ¹²⁵I seed strand implantation in malignant obstructive jaundice. METHODSWe enrolled 67 patients between January 2016 and June 2018 with malignant obstructive jaundice and randomized them into a biliary stent combined with ¹²⁵I seed strand treatment (combined) group (n = 32) and biliary stent (control) group (n = 35). All patients underwent enhanced computed tomography and magnetic resonance imaging and were tested for biochemical and cancer markers. Twelve patients underwent pathological examination before surgery. All patients were followed up by telephone or clinical visit. Postoperative liver function improvement, postoperative complications, stent patency time, and survival time were compared between the two groups. Prognostic risk factors were evaluated. RESULTSTechnical success was achieved in all patients in both groups. Postoperative liver function improved significantly in all patients (total bilirubin, direct bilirubin, alanine aminotransferase, and aspartate aminotransferase decreased significantly in all patients, the P values were less than 0.05). There was no significant difference in preoperative or postoperative indexes between the two groups for changes in total bilirubin (P = 0.147), direct bilirubin (P = 0.448), alanine aminotransferase (P = 0.120), and aspartate aminotransferase (P = 0.387) between the two groups. The median stent patency time of the combined group was 9.0 ± 1.4 mo [95% confidence interval (CI): 6.3-11.8 mo], which was significantly longer than the that of the control group (6.0 ± 0.3 mo, 95%CI: 5.5-6.5 mo, P = 0.000). The median survival time of the combined group was 11.0 ± 1.4 mo (95%CI: 8.2-13.7 mo), which was significantly longer than that of the control group (7.0 ± 0.3 mo, 95%CI: 6.4-7.6 mo, P = 0.000). Location of obstruction and number of stents were independent risk factors affecting prognosis.CONCLUSIONBiliary stent combined with ¹²⁵I seed strand implantation is safe and effective in malignant obstructive jaundice and improves stent patency time and median survival time.     

双源CT在经颈静脉门腔分流术后随访中的应用

目的 观察双源CT在经颈静脉肝内门-体分流术(TIPS)后随访中的应用价值。方法 对28例肝硬化门静脉高压合并上消化道出血或大量腹腔积液接受TIPS的患者,于术后1个月内、3个月内、6个月、12个月、18个月、24个月进行双源CT复查,采用MIP、VR等图像后处理技术,判断肝静脉及门静脉间支架位置通畅情况。结果 28例患者中,3例(10.71%)支架内血栓形成,MIP示支架处低密度灶,对比剂自狭窄处流过,VR示支架位置、角度满意,及时行球囊扩张溶栓治疗;1例(3.57%)支架冗长、成角,再次植入支架;24例(85.71%)TIPS术后未出现分流道狭窄或血栓,MIP成像显示支架通畅,内见对比剂通过,VR显示支架位置、角度满意。结论 双源CT血管成像技术具有安全、无创、准确的优点,且同时能对肝实质进行观察,可作为TIPS术后的首选随访手段。     

CT透视引导下经皮放射性125I粒子永久植入治疗肺恶性肿瘤

目的探讨CT透视(CTF)引导下125I粒子永久植入治疗肺癌的临床应用价值。方法对24例肺恶性肿瘤患者施行CTF引导下经皮穿刺放射性粒子125I永久植入进行组织间放疗,包括原发性肺癌15例(15个病灶),转移性肺癌9例(13个病灶),共28个病灶,最大直径2.1～7.6cm(中位直径3.95cm),单个病灶的处方剂量80～100Gy。术后定期观察并发症情况,分析肿瘤局部控制率,使用Kaplan-Meier法统计生存率。结果所有患者均成功耐受手术,手术耗时30～75min(中位时间46min),无手术相关严重并发症发生;3例穿刺侧出现少量气胸,4例术后穿刺针道少量出血,无咯血;随访期间未发现放射性肺炎。中位随访时间31.5个月(8～46个月),病灶局部控制率78.57%(22/28);3年累积生存率为55.00%,中位生存时间为38个月(8～46个月),原发性肺癌和转移性肺癌患者生存率差异无统计学意义。结论 CTF为经皮穿刺放射性粒子植入提供实时引导和准确定位,可缩短手术时间,减少手术相关并发症。肺部恶性肿瘤125I粒子组织间放疗可达到理想的肿瘤局部控制率,延长患者生存时间。     

经皮经肝选择性门静脉栓塞技术及其安全性评价

目的 探讨经皮经肝选择性门静脉栓塞术(SPVE)的技术要点和安全性.方法 对41例肝脏肿瘤患者(包括原发性肝癌13例,转移性肝癌28例)行SPVE,对其中32例同期行TACE术(SPVE+ TACE组),9例未行或未同期行TACE术(单纯SPVE组).术后回顾性分析SPVE的技术要点、并发症及临床安全性.结果 对41例均成功完成SPVE术,成功率100％;术后第3天患者ALT、AST、TB较术前升高,SPVE+TACE组升高更为明显,至术后第7天均明显下降.5例出现SPVE相关并发症,包括2例异位门静脉栓塞、1例暂时性肝功能衰竭、1例肝包膜下出血和1例肝内门静脉-静脉瘘.结论 SPVE作为肝脏外科手术和TACE术的重要辅助技术是可行的,但术后相关并发症应引起足够重视.     

肝细胞癌合并门脉瘤栓的TACE疗效评价

目的 评价ＴＡＣＥ治疗肝癌合并门脉瘤栓的疗效,材料与方法：经ＴＡＣＥ治疗的合门脉瘤栓的ＨＣＣ患者５９例,主干瘤栓２９例,一级分支瘤栓３０例,根据栓塞方法分为：ＧＳ组（ｎ＝２１）,ＬＰ组（ｎ＝１０）,混合组（ｎ＝２８）。分别以瘤栓变化及生存时间作为近,远期疗效评价指标,结果;３组近期疗效有效率分别为３８．１％,０％,５０％,ＧＳ组及混合组疗效优于ＬＰ组（Ｐ〈０．０５）,３种ＴＡＣＥ方法对门脉瘤栓缩小     

Stratification of portal vein-invaded hepatocellular carcinoma treated with transarterial chemoembolization monotherapy

PurposeThe study aimed to establish a prognostic prediction model and an artificial neural network (ANN) model to determine who will benefit from transarterial chemoembolization (TACE) monotherapy for patients with hepatocellular carcinoma (HCC) invading portal vein.MethodsTreatment-naïve patients with HCC and portal vein invasion who were treated with TACE monotherapy at hospital A as training cohort and hospital B as validation cohort were included. The primary endpoint was overall survival (OS). In training cohort, independent risk factors associated with OS were identified by univariate and multivariate analysis. The prognostic prediction (PP) and ANN models based on the independent risk factors were established to find out who will benefit most from TACE monotherapy. The type of portal vein tumor thrombosis was classified based on the Cheng’s Classification. The accuracy of the models was validated in validation cohort.ResultsTotally, 242 patients (training cohort: n ​= ​159; validation cohort: n ​= ​83) were included. The median OS was 7.1 and 8.5 months in training and validation cohort, respectively. In training cohort, the PP model was established based on the following five independent risk factors: Cheng’s Classification, Eastern Cooperative Oncology Group score, maximum tumor size, number of HCC nodules, and Child-Pugh stage. PP score of 17.5 was identified as cut-off point and patients were divided into two groups by PP score <17.5 and >17.5 in survival benefit and prognostication (8.8 vs. 5.5 months; P ​< ​0.001). These five factors were included and ranked based on the importance associated with OS in the ANN model. Both of the two models received high accuracy after validation.ConclusionsPortal vein invaded HCC patients with PP score <17.5 may benefit most from TACE monotherapy. For these patients, TACE monotherapy should be considered.