肝切除术前PEIT治疗小肝癌28例

目的 探讨可切除的小肝癌术前PEIT的临床价值.方法 2000年1月～2002年11月收治的67例可切除小肝癌患者随机分成术前PEIT组(n=28)与Ⅰ期手术组(n=39)所有患者术后病理均证实为肝细胞癌.对比两组标本间肿瘤坏死、纤维包膜、子灶、门静脉血栓、肝硬化等病理情况.结果 术前PEIT组较Ⅰ期手术组肿瘤坏死广泛...     

术前TACE对可切除大肝癌术后无瘤生存率及生存率的影响

目的 分析术前经导管肝动脉化疗栓塞(TACE)对可切除大肝癌术后无瘤生存率及总生存率的影响,探讨可切除大肝癌术前TACE意义. 方法 108例大肝癌病例分成术前TACE组(n=52)与一期手术组(n=56),进行随访,并根据有无肉眼子灶、癌栓分组对照作生存分析. 结果 二期手术组与一期手术组无瘤生存率及总生存率差异无统计学意义. 结论可切除大肝癌术前TACE并未能提高无瘤生存率及总生存率,应首选手术治疗.     

可切除肝细胞肝癌并门静脉主支癌栓治疗策略的安全性和有效性分析

目的。探讨肝功能代偿期手术切除或TACE治疗肝细胞肝癌（HCC）合并门静脉主支癌栓的疗效,以及TACE后选择性肝切除术的安全性。方法选择肝功能Child．PughA可切除的原发性肝癌并门脉主支癌栓患者116例,并分为手术组（56例）和肝动脉化疗栓塞组（TACE组,60例）,其中TACE组治疗后肿瘤反应评价有效,接受进一步手术治疗的患者纳入TACE＋手术组。对比3组患者的治疗效果和生存情况。结果手术组1例术中死亡（1／56,1．78％）,并发症发生率高于TACE组（16／56US7／60,P=0．010）。手术组、TACE组和TACE＋手术组的中位生存时间为11．41、15．34、22．01个月,TACE＋手术组的生存时间明显长于手术组（P=0．040）。手术组1、2、5年生存率分别为47．27％、24．58％、5．67％;TACE组分别为53．91％、27．18％、6．34％：TACE＋手术组分别为79．17％、45．83％、16．67％。多因素分析提示肝硬化、肿瘤位置是患者独立预后相关因素。结论HCC合并门静脉主支癌栓肝功能代偿良好可切除者,首治TACE后选择性肝切除术是更安全和有效的治疗策略。     

肝细胞癌组织学类型与化疗栓塞疗效关系的研究

目的 研究肝细胞癌组织学类型与化疗栓塞（TACE）疗效的关系。方法 117例肝细胞癌,单纯手术组58例,TACE后Ⅱ期手术切除（TACE组）59例,按组织学类型和病理分级进行病理资料、生存资料分析。结果 GACE组较单纯手术组,肿瘤坏死更广泛,体积缩小,包膜更完整,淋巴细胞浸润多,纤维化多;其梁索型、索状腺样型、透明细胞型和Ⅰ-Ⅱ级较实体型、低（未）分化型和Ⅲ-Ⅳ级上述改变更明显。TACE组1,2,3年生存率,分别为89.8%,61.0%,49.2%,单纯手术分别为75.9%,56.9%,34.5%。结论 TACE疗效存在组织学类型差异;它和手术切除联合可改善肝细胞癌患者的预后。     

原发性肝癌瘤周肝组织内微转移的回顾性与前瞻性研究

目的探讨原发性肝癌癌周肝组织内微转移的分布情况，以确定肝癌切除所需要的切缘最小值。方法回顾性分析本组114例无肉眼癌栓或子灶的肝癌病人120次手术标本常规病理切片629张，前瞻性研究本组连续76例术前影像学检查未发现癌栓或子灶的肝癌手术标本及石蜡切片645张。肉眼观察肿瘤距切缘的大小、有无子灶或癌栓，镜下观察有无包膜、有无微卫星灶或微癌栓并测量其远端距肿瘤边缘的距离。采用SPSS10．0和SAS6．12统计软件包分析。结果回顾组120例次肝癌病人中：26例次（21．7％）瘤外肝组织内发现微转移灶；在95％、99％和100％的病例中微转移灶分别在距原发瘤边缘或包膜外3．9mm、5．9mm和6．7mm以内。前瞻组76例肝癌病人：无肉眼癌栓或子灶的59例病人中25例（42．1％）发现瘤外肝组织内微转移灶，在95％、99％和100％的病例中微转移灶分别在距原发瘤边缘或包膜外4．5mm、5．5mm和6．0mm以内；而术前影像学检查未发现而术中探查发现有肉眼癌栓或子灶的18例病人中14例（77．8％）发现瘤外肝组织内微转移灶，在95％、99％和100％的病例中微转移灶分别在距原发瘤边缘或包膜外18．5mm、18．5mm和19．0mm以内。结论对无肉眼癌栓或子灶、无肝外转移的肝癌切除99％和100％的微转移灶所需最小切缘分别为5．5mm和6mm；而对有肉眼癌栓或子灶的肝癌切除99％的微转移灶所需最小切缘应〉18．5mm。     

术前介入对合并门脉侵犯肝癌术后生存影响的前瞻性研究

目的前瞻性对合并门脉侵犯可切除肝癌患者术前行肝动脉栓塞化疗（TACE）,研究探讨该方法的有效性及安全性。方法术前影像学及多学科诊断为可切除肝癌合并门脉侵犯患者219例,按初始治疗分为一期手术切除的手术组（132例）和TACE组（87例）,TACE组患者先行TACE治疗后再行手术切除。分层分析两组间的生存差异。结果手术组和TACE组1、3、5年生存率和中位生存时间分别为52.4%、19.1%、13.1%、13.87个月和57.1%、27.2%、21.1%、16.13个月（P=0.037）。亚组分析中,段叶级癌栓手术组和TACE组1、3、5年生存率分别为61.0%、32.1%、20.1%和92.9%、55.7%、47.8%（P=0.012）。主分支癌栓中两组生存率差异无统计学意义（P=0.272）。两组术后死亡率及并发症发生率差异无统计学意义。结论伴有门脉侵犯可切除肝癌术前行肝动脉栓塞化疗安全有效,尤其可以显著延长伴有段叶级侵犯肝癌患者的生存。     

原发性肝癌全肝切除标本的病理解剖学特征及其启示

目的 探讨原发性肝癌的病理解剖学特征及其意义.方法 2000年8月至2007年12月共有89例肝硬化合并原发性肝癌患者接受肝移植手术,收集手术切除标本及受侵犯的邻近组织和肿大的淋巴结.将标本沿冠状切面每隔1.0 cm切开,观察肝癌的大小、数目、分布、包膜、门静脉瘤栓、卫星灶,并记录卫星灶与主瘤问的距离、受肝癌侵犯的组织、淋巴结等,然后送病理学检查,最终诊断以病理报告为准.结果 89例患者中,肝细胞肝癌86例,胆管细胞性肝癌3例;多发肿瘤53例,单发肿瘤36例;13例主瘤在右叶,但左叶存在小癌灶;14例有较完整的包膜,75例无包膜,无包膜病例中11例边界不清;术中所见侵犯邻近组织的25例患者中,8例经病理证实,16例的肿大淋巴结中7例有癌浸润;有门静脉主干或分支瘤栓者42例(47.2%),有卫星灶者39例(43.8%),瘤栓与卫星灶随肿瘤体积、数目增加而增加;卫星灶距主瘤距离多为0.5～3.0 cm,少数达5.0 cm.结论 全肝切除标本能全面地反映肝癌牛长和浸润特征.应警惕门静脉瘤栓及卫星灶的存在,特别是距主瘤较远的卫星灶及门静脉小支内的瘤栓,以及分布在另一肝叶的小癌灶.这些因素在影像学检查时容易漏诊,但会影响肝切除术或肝移植术的疗效.     

原发性肝癌全肝切除标本的病理解剖学特征及其启示

目的 探讨原发性肝癌的病理解剖学特征及其意义.方法 2000年8月至2007年12月共有89例肝硬化合并原发性肝癌患者接受肝移植手术,收集手术切除标本及受侵犯的邻近组织和肿大的淋巴结.将标本沿冠状切面每隔1.0 cm切开,观察肝癌的大小、数目、分布、包膜、门静脉瘤栓、卫星灶,并记录卫星灶与主瘤问的距离、受肝癌侵犯的组织、淋巴结等,然后送病理学检查,最终诊断以病理报告为准.结果 89例患者中,肝细胞肝癌86例,胆管细胞性肝癌3例;多发肿瘤53例,单发肿瘤36例;13例主瘤在右叶,但左叶存在小癌灶;14例有较完整的包膜,75例无包膜,无包膜病例中11例边界不清;术中所见侵犯邻近组织的25例患者中,8例经病理证实,16例的肿大淋巴结中7例有癌浸润;有门静脉主干或分支瘤栓者42例(47.2%),有卫星灶者39例(43.8%),瘤栓与卫星灶随肿瘤体积、数目增加而增加;卫星灶距主瘤距离多为0.5～3.0 cm,少数达5.0 cm.结论 全肝切除标本能全面地反映肝癌牛长和浸润特征.应警惕门静脉瘤栓及卫星灶的存在,特别是距主瘤较远的卫星灶及门静脉小支内的瘤栓,以及分布在另一肝叶的小癌灶.这些因素在影像学检查时容易漏诊,但会影响肝切除术或肝移植术的疗效.     

原发性肝癌全肝切除标本的病理解剖学特征及其启示

目的 探讨原发性肝癌的病理解剖学特征及其意义.方法 2000年8月至2007年12月共有89例肝硬化合并原发性肝癌患者接受肝移植手术,收集手术切除标本及受侵犯的邻近组织和肿大的淋巴结.将标本沿冠状切面每隔1.0 cm切开,观察肝癌的大小、数目、分布、包膜、门静脉瘤栓、卫星灶,并记录卫星灶与主瘤问的距离、受肝癌侵犯的组织、淋巴结等,然后送病理学检查,最终诊断以病理报告为准.结果 89例患者中,肝细胞肝癌86例,胆管细胞性肝癌3例;多发肿瘤53例,单发肿瘤36例;13例主瘤在右叶,但左叶存在小癌灶;14例有较完整的包膜,75例无包膜,无包膜病例中11例边界不清;术中所见侵犯邻近组织的25例患者中,8例经病理证实,16例的肿大淋巴结中7例有癌浸润;有门静脉主干或分支瘤栓者42例(47.2%),有卫星灶者39例(43.8%),瘤栓与卫星灶随肿瘤体积、数目增加而增加;卫星灶距主瘤距离多为0.5～3.0 cm,少数达5.0 cm.结论 全肝切除标本能全面地反映肝癌牛长和浸润特征.应警惕门静脉瘤栓及卫星灶的存在,特别是距主瘤较远的卫星灶及门静脉小支内的瘤栓,以及分布在另一肝叶的小癌灶.这些因素在影像学检查时容易漏诊,但会影响肝切除术或肝移植术的疗效.     

可切除大肝癌术前TACE对手术前后肝功能的影响

目的 探讨可切除大肝癌术前TACE对手术前后肝功能的影响。方法 分析2002年1月至2003年1月78例可切除大肝癌患者，其中31例术前行TACE，47例术前未经TACE(对照组)。分析两组术前肿瘤大小、肝功能指标变化、手术探查情况及手术相关因素、术后肝功能指标变化及并发症情况的差异。结果 TACE组术前7-球蛋白水平升高，术后前白蛋白水平下降，手术探查见肿瘤周围粘连明显增加，肝硬化加重，手术时间延长。两组间肝门阻断时间、术中平均出血量、术后并发症等指标无显著差异，TACE组TACE后平均肿瘤直径缩小并不显著。结论 大肝癌术前TACE使肝功能受损，增加手术难度及手术风险，并有可能耽误手术时机。     

Portal vein tumor thrombus from colorectal cancer with no definite metastatic nodules in liver parenchyma

Portal vein tumor thrombus (PVTT) in hepatocellular carcinoma (HCC) is a common entity. In colorectal liver metastasis, microscopic tumor invasion into the intrahepatic portal vein is also usually observed, but the incidence of macroscopic tumor thrombus in the first branch and trunk of the portal vein is rare. Most reported cases of PVTT from colorectal cancer had concomitant metastatic nodules in liver parenchyma, and the PVTT was continuous with the liver nodule, like PVTT in HCC. We present a case of PVTT from colorectal cancer with no definite metastatic nodules in liver parenchyma. A 58-year old man underwent laparoscopic high anterior resection for rectosigmoid carcinoma accompanied by bulky tumor thrombus in the branch of the inferior mesenteric vein. Six months later, he received left lobectomy and left caudate resection for liver metastasis. The resected specimen demonstrated there was no metastatic nodule in liver parenchyma and that the left portal system was filled with the tumor thrombus. The patient is alive with no sign of recurrence 66 months after hepatectomy. Even if there is a macroscopic PVTT from colorectal cancer, a better prognosis may be expected when the tumor can be completely resected en-bloc by anatomic hepatectomy including PVTT.     

可切除肝细胞癌合并门静脉癌栓的外科治疗

背景与目的 对于肝细胞癌（HCC）合并门静脉癌栓（PVTT）患者而言,手术切除率低,复发率高,预后较差,其治疗方式目前仍有很多争议。笔者总结可切除HCC合并PVTT的外科治疗经验,比较手术与肝动脉化疗栓塞术（TACE）对此类患者的近远期疗效。方法 回顾性分析云南省临沧市人民医院2016年3月—2021年3月收治的39例可切除HCC合并PVTT患者的临床资料,其中23例患者施行手术治疗（手术组）,16例行TACE治疗（TACE组）。比较两组患者的相关临床资料与预后,并分析影响患者预后的因素。结果 手术组除1例肿瘤广泛侵犯仅取材活检,其余均完成手术,无手术死亡;19例示切缘阴性;2例术后肝功能不全,经人工肝及其他支持治疗痊愈出院。TACE组16例肝动脉超选、灌注、栓塞顺利;1例因肝动脉完全栓塞,术后3 d因急性肝衰竭救治无效死亡。手术组8例术后辅助TACE治疗,5例靶向治疗,其中1例I型PVTT患者手术后联合TACE等治疗后仍生存47个月。TACE组13例多次治疗,4例给靶向药物,其中1例II型PVTT患者TACE术后经过7次灌注化疗及栓塞仍然生存25个月。与TACE组比较,手术组住院时间延长、医疗成本增加、术后行TACE的例数更少、术后未做其他治疗的例数以及术后AFP恢复正常的例数更多（均P<0.05）。手术组与TACE组的中位生存期分别为16.2个月与9.5个月;0.5、1、2、3年生存率分别为65.2%、43.5%、34.8%、17.4%与46.7%、33.3.0%、13.3%、0。两组患者中位生存期与累积生存率差异均有统计学意义（均P<0.05）。单因素分析结果显示,PVTT分型、甲胎蛋白（AFP）水平、肿瘤大小、肿瘤数目与患者术后生存时间有关（均P<0.05）;多因素分析结果显示,治疗方式、PVTT分型、肿瘤直径、AFP水平是患者术后生存时间的独立影响因素（均P<0.05）。结论 PVTT分型、肿瘤直径、AFP水平直接影响HCC合并PVTT患者的术后生存,外科手术切除治疗效果明显好于TACE治疗,尤其是对于可切除HCC合并I/II型PVTT的患者,但治疗选择可能受患者意愿、经济因素等的限制。     

Adjuvant transcatheter arterial chemoembolization improves efficacy of hepatectomy for patients with hepatocellular carcinoma and portal vein tumor thrombus

Purpose

To study the value of postoperative transcatheter arterial chemoembolization (TACE) to improve the efficacy of hepatectomy and tumor thrombus removal for patients with hepatocellular carcinoma (HCC) and portal vein tumor thrombus (PVTT).

Experimental design

From January 1996 to December 2004, 126 patients with HCC and PVTT were randomly assigned into 2 groups: a control group and a TACE group. The control group underwent liver resection combined with PVTT removal, and the TACE group underwent liver resection combined with adjuvant TACE after surgery. Survival time in the 2 groups was studied.

Results

The 2 groups were comparable with regard to all clinicopathologic data. The median survival time was 13 months (95% confidence interval [CI] 6.25 to 19.75 months) for the TACE group and 9 months (95% CI 6.90 to 11.10 months) for the control group. Estimated survival rates for 1, 3 and 5 years were better in the TACE group (50.9%, 33.8%, 21.5%; respectively) than the control group (33.3%, 17.0%, 8.5%, respectively; log rank P = .0094).

Conclusions

Postoperative TACE enhances the effect of liver resection combined with PVTT removal for HCC patients with PVTT.     

Surgical treatment of hepatocellular carcinoma in China

Background and aims Surgery remains the most effective treatment for hepatocellular carcinoma (HCC). While resection and liver transplantation achieve the best outcomes in patients with small HCC, controversy surrounds treatment of large HCC, HCC with portal vein tumor thrombus, and HCC with hypersplenism.Patient/methods From January 1988 to December 2002, 2,102 patients with large HCC underwent hepatectomy in our hospital. The traditional resection method was used on 959 patients, after which the improved new method was used on 1,143 patients. Meanwhile, from January 1990 until December 2003, hepatic resection ± thrombectomie has been performed in 438 patients with HCC and portal vein tumor thrombus. Among them, 286 patients showed portal vein tumor thrombus located in the primary and secondary branch of the main portal vein (group A), and 152 patients showed portal vein tumor thrombus (PVTT) involved in the main portal vein (group B). Additionally, out of 204 HCC patients with cirrhotic hypersplenism, 94 patients had hepatectomy and splenectomy, and 100 patients had only hepatectomy without hospital death.Results The 3- and 5-year survival after resection of large HCCs (over 5 cm) with improved new method in China was between 50.7 and 58.8% and 27.9 and 38.7%, respectively. Tumor recurrence in the liver within 1 year after hepatic resection + thrombectomie was detected in 45% of group A and in 78.8% in group B. The cumulative 5-year overall survival rates were 18.1% for group A and 0% for group B. The 1-, 3-, and 5-year overall survival in HCC plus portal vein tumor thrombus (PVTT) was 58.7, 22.7, and 18.1%. The hepatectomy/splenectomy group had a 5-year tumor-free survival rate of 37.2% and the hepatectomy group alone had 27.2%.Conclusion The new resection methods, hepatic resection + thrombectomy and hepatectomy + splenectomy, are very effective treatments for large HCC, HCC with portal vein tumor thrombus, and HCC with hypersplenism, respectively. Local treatment modalities, e.g. percutaneous ethanol injection, cryosurgery, and radiofrequency ablation as well as microwave coagulation are used in patients with poor liver function in small and large HCCs.     

Is Preoperative Transarterial Chemoembolization Needed for a Resectable Hepatocellular Carcinoma?

Background Whether preoperative transarterial chemoembolization (TACE) has the therapeutic benefits in patients with resectable hepatocellular carcinoma (HCC) remains uncertain. Materials and methods We retrospectively investigated the influence of preoperative TACE on both disease-free survival and the pattern of recurrence after curative resection. From March 1998 to January 2005, a series of 273 patients who underwent curative resection for HCC were reviewed. Altogether, 120 patients underwent preoperative TACE, and 153 patients did not. We compared disease-free survival and the recurrence patterns between TACE and non-TACE groups, as well as between subgroups, stratified with regard to initial tumor size (≤3 cm, 3–5 cm, >5 cm) and pathologic tumor stage (stage I-II and stage III-IVa). We also compared disease-free survival and the pattern of recurrence among the three groups: complete necrosis, incomplete necrosis, non-TACE groups. Results The 1-, 3-, and 5-year disease-free survival rates were 76.0%, 57.7%, and 51.3%, respectively, in the TACE group and 70.9%, 53.8%, and 46.8%, respectively, in the non-TACE group. No significant difference was observed in disease-free survival or the pattern of recurrence between the TACE and non-TACE groups. Further analysis of disease-free survival and the pattern of recurrence between subgroups according to initial tumor size and tumor stage showed no significant differences. Complete necrosis of tumor was recognized in only 33 patients of the TACE group (p = 0.001). Among the three complete necrosis, incomplete necrosis, and non-TACE groups, no significant difference was observed in disease-free survival or the pattern of recurrence. Conclusions Preoperative TACE did not significantly improve the disease-free survival or the pattern of recurrence after curative resection of HCC. Even though this study is a retrospective analysis, preoperative TACE cannot be recommended as a routine procedure before hepatectomy for a resectable HCC.     

术前TACE对肝细胞肝癌患者肝切除术后预后的影响

目的：探讨术前经肝动脉化疗栓塞术（TACE）对肝细胞肝癌（HCC）肝切除患者生存及预后的影响。方法：对479例行肝切除并经病理确诊、临床资料完整的HCC患者进行回顾性分析,除外失访及死亡者50例,余按TACE时机分为2组,其中术前TACE组50例,术前无TACE组379例。对2组患者的临床病理资料行χ2检验,Kaplan-Meier分析术后无瘤生存率及预后。结果：术前2组患者在性别、病灶数目、肿瘤最大径、AFP、HBV感染、静脉癌栓、肝切除范围及肝硬化等方面差异均无统计学意义（P〉0.05）。但术前TACE组患者年龄比术前无TACE组小（χ2=6.228,P=0.012）,且肿瘤分化程度低、坏死率高（χ2=53.874,P=0.000）。2组患者无瘤生存率及总体生存率差异均无统计学意义（χ2=0.736,P=0.391;χ2=0.000,P=0.995）。结论：不能一期切除的肝细胞肝癌患者,经TACE后行手术治疗,其无瘤生存率及预后与直接手术相似。     

可切除肝癌术前经肝动脉化学药物栓塞对肝切除手术的影响

目的 探讨可切除肝癌术前经肝动脉化学药物栓塞对肝切除手术的影响。方法 回顾分析了自1996年1月至1997年1月收治的126例患者，术前经肝动脉化学药物栓塞组（TACE组）62例，术前未经肝动脉化学药物栓塞组64例。对比2组手术前后肝功能指标变化，手术所见，肝门阻断时间，术中平均出血量，平均手术时间，术后1、2、3d腹腔引流量，手术死亡率及并发症发生情况。结果 2组手术前后肝功能改变无差异，2组均无手术死亡。手术中发现术前TACE组胆囊壁增厚、萎缩、粘连及癌灶与膈肌、侧腹壁和网膜粘连远比非TACE多。TACE组肝硬化加重，手术时间延长，术中失血量及术后1、2、3d腹腔引流量多，2组之间手术并发症差异无显著意义。结论 术前TADE使手术难度及危险性增加，对可切除肝癌术前进行TACE应持慎重态度。     

Role of Preoperative Transcatheter Arterial Chemoembolization for Resectable Hepatocellular Carcinoma: Relation between Postoperative Course and the Pattern of Tumor Recurrence

The effects of preoperative transcatheter arterial chemoembolization (TACE) were retrospectively evaluated in patients with resectable hepatocellular carcinoma (HCC). A total of 227 patients who underwent hepatectomy for HCC were studied (146 underwent preoperative TACE and 81 did not). We compared operative outcome, mortality, and disease-free survival between TACE and non-TACE groups. We also compared the pattern of recurrence and postrecurrence survival between subgroups according to staging. Of the 227 patients, 105 with tumor stage I-II were assigned to group A (group A/TACE, n = 69; group A/non-TACE, n = 36), and the remaining 122 with tumor stage III-IV were assigned to group B (group B/TACE, n =77; group B/non-TACE, n =45). Complete necrosis was found to be more frequent in the TACE group (p < 0.01). Operating time, blood loss, and mortality did not differ between those who did and did not undergo preoperative TACE. TACE did not significantly improve disease-free survival within either the entire TACE group or group A/TACE. In contrast, in group B/TACE the disease-free survival rates were significantly higher than in group B/non-TACE. Furthermore, both extrahepatic metastasis and diffuse intrahepatic metastasis were significantly more frequent in group B/non-TACE than in group B/TACE. The preoperative TACE also improved the postrecurrence survival in group B. We speculate that preoperative TACE reduced tumor recurrence and that it might confer a survival advantage after surgery, particularly in patients with advanced HCC. In addition, it is expected that this procedure may improve the pattern of tumor recurrence when it does occur.