原位肝移植治疗原发性肝癌６８例报告

目的：探讨原位肝移植在原发性肝癌治疗中的价值。方法：对６８例接受肝移植原发性肝癌病例进行回顾性分析,随访６个月以上,对术后患者存活情况进行分析。结果：６８例肝移植手术均获成功,无围手术期死亡,５４例存活至今,最长无瘤存活已达６５个月。小肝癌复发率为２.２％（１／４６）,大肝癌复发率为５４.５％（１２／２２）,其中肝内门脉分支有癌栓者复发率为６６.６％（４／６）,门脉主干有癌栓者为１００％（３/３）;小肝癌患者的存活时间显著长于大肝癌（Ｐ＝０.０００）。此外,肝癌肝移植术后及早停用类固醇激素,并维持抗排斥药物在较低的药物浓度也可能有助于减少肿瘤术后复发。结论：原位肝移植是治疗肝癌特别是小肝癌的有效手段,对于门静脉主干无癌栓的中晚期肝癌也能起到积极治疗作用。     

Primary vascular tumours of the kidney

Primary vascular tumours of the kidney are rare and may pose diagnostic difficulties because of their similar clinical, morphological, and immunohistochemical features. This article summarizes the clinical and pathological features of primary renal angiosarcoma and anastomosing haemangioma of the kidney including epidemiology, genetics, and prognosis. Renal anastomosing haemangiomas are benign neoplasms characterized by anastomosing capillary-sized vascular channels. These tumours are rare, with about 75 cases reported in the literature. Most anastomosing haemangiomas are found incidentally on ultrasound, computed tomography, or magnetic resonance imaging. Common symptoms include abdominal pain, haematuria, and abdominal mass. Renal anastomosing haemangiomas are characterized by recurrent mutations in GNAQ and GNA14 genes. The prognosis of anastomosing haemangioma is excellent. Primary renal angiosarcomas are malignant tumours showing endothelial differentiation. To date, 76 cases have been described in the literature. Primary renal angiosarcomas are frequently symptomatic. The clinical features of renal angiosarcomas are similar to those of renal anastomosing haemangiomas, including abdominal pain, haematuria, and abdominal mass. Angiogenesis-related genes and vascular-specific receptor tyrosine kinases such as KDR, TIE1, SNRK, TEK, and FLT1 are upregulated in angiosarcomas. Primary renal angiosarcomas are highly aggressive neoplasms with a poor prognosis despite surgical treatment, chemotherapy, radiotherapy, or targeted therapy.     

Clinical and imaging experience with yttrium-90 microspheres in the management of unresectable liver tumours.

INTRODUCTION: Selective internal radiation therapy (SIRT) is emerging as a new therapeutic modality in recent years for management of non-resectable hepatic malignancies. Our experience in clinical application of this treatment is reported here. MATERIAL AND METHODS: From June 2004, patients whose liver tumours were no longer amenable for any conventional treatment with either chemotherapy or surgery were considered for yttrium-90 microspheres treatment after discussion at our multidisciplinary meeting. A pre-treatment planning was carried out with visceral angiography and technetium-99m macroaggregated albumin (MAA) for assessment of both tumour volume and extrahepatic shunting in addition to a baseline PET and CT scans, respectively. Two weeks later, a second visceral angiogram was performed to deliver the calculated dosage of microspheres into the arterial system supplying the tumour. Patients were then followed up with tumour markers, repeat PET and CT scans of abdomen at 6 weeks and 3 monthly thereafter. RESULT: Twenty-one patients (F=11, M=10; age range 40-75 years, mean=58 years) received yttrium-90 microspheres consisting of liver metastases from colorectal primary (n=10) and non-colorectal primaries (n=8), and primary liver tumours (n=3). One patient received 2 treatments. The mean administered activity of microspheres delivered was 1.9 GBq (range 1.2-2.5 GBq). Injection of microspheres had no immediate effect on either clinical haematology or liver function tests. At follow-up, 86% of patients showed decreased activity on PET scan at 6 weeks (p=0.01). The mean pre-treatment SUV was 12.2+/-3.7 and the mean post-treatment SUV was 9.3+/-3.7, indicating a significant improvement measured with PET activity. Only 13% showed a reduction in the size of tumour on CT scan. For patients with colorectal liver metastases, there was no significant reduction in CEA level (127+/-115 vs 75+/-72 micro/l, p=0.39). Complications were seen in 4 patients (19%) including radiation hepatitis (n=2), cholecystitis (n=1) and duodenal ulceration (n=1). All resolved without surgical intervention. Seven patients died at follow-up from progressive extrahepatic disease (33%). CONCLUSION: SIRT should be considered for patients with advanced liver cancer. It has a significant effect on liver disease in the absence of extrahepatic disease. PET imaging has an integral role in the assessment of patients treated with yttrium-90 SIR-Spheres.     

A Case of Epithelioid Hemangioendothelioma in the Liver

A 15-year-old girl was admitted to our hospital with a 9-month history of upper abdominal pain and loss of appetite. Her history showed no indication of hepatitis. Her abdomen appeared to be even and soft, and the liver and spleen could not be felt below the costal margin. Percussion pain in hepatic region was negative. Gastroscopy showed no abnormalities. An abdominal ultrasound examination revealed the presence of hepatic hypoechoic areas and an abdominal CT scan showed multiple roundlike low-density masses in both hepatic lobes. The edges of the focal lesions were smooth and continuous, with a heterogeneous center, the round-like edges were enhanced, but the enhancement in the focal lesions was not obvious.[第一段]     

非转流腔静脉成形肝移植术中容量管理的探讨

目的:探讨原发性肝癌肝移植非静脉转流术中容量管理的特点与方法.方法:52例原发性肝癌行腔静脉成形术非转流肝移植术患者,采用静吸复合全身麻醉.术中监测血流动力学、血气、生化指标、凝血功能、体温、尿量及出血量等.根据腔静脉成形术非转流肝移植术中各期的特点和术中具体情况连续推注小剂量多巴胺等活性药物,并在低中心静脉压(CVP)根据血流动力学与血气分析指标决定输液种类和数量.结果:围术期血流动力学基本平稳.pH值和BE等代谢指标变化较大.血浆乳酸浓度切肝期降低,在无肝期、新肝期升高.无肝期尿量维持有效量,血浆肌酐(Cr)在新肝期增高.结论:静脉成形术非转流肝移植的术中容量管理相当重要与复杂,选用连续输注小剂量多巴胺,并以低CVP控制静脉压的容量管理,根据监测指标决定输液种类和数量,能维持有效容量,达到循环稳定,改善肾功能.     

Pre-operative diagnostic biopsy and surgery in paediatric liver tumours—the Amsterdam experience

AIM: To report 24 years of pre-treatment biopsy and surgical experience in primary liver tumours in children. METHODS: Between 1979 and 2003, 53 children presented with a primary liver tumour of whom 48 who underwent surgical resection were evaluated (two died, two were unresectable, and one was transplanted). Biopsy data, per- and post-operative complications, mortality, and survival were retrospectively reviewed. RESULTS: Benign tumours were diagnosed in eight patients. Surgical resection for a malignant tumour was performed in 40 patients (26 hepatoblastomas (HB), eight hepatocellular carcinomas (HCC) (four had fibrolamellar HCC), three rhabdomyosarcomas (RMS), one neuroblastoma, one non-hodgkin lymphoma (NHL), and one teratoma). Primary resection was performed in one HB, and four HCCs. The cumulative survival without evidence of disease was 73% for HB (median 7 years) and 88% for HCC (median 3.5 years). CONCLUSION: The treatment results are comparable with those of larger international series except for HCC. The existing diagnostic pitfalls in differentiating between the various liver malignancies justify the use of a diagnostic biopsy.     

A proposed TNM classification for malignant primary liver tumours

On the basis of 211 hepatic resections and reresections, a study was made to evaluate the possibility of compiling a checklist for primary liver tumours according to the TNM classification. This would aid the surgeon in planning therapy and provide a useful guide for prognosis and late results.     

LIVER TRANSPLANTATION FOR HEPATIC CANCER

ＬＩＶＥＲＴＲＡＮＳＰＬＡＮＴＡＴＩＯＮＦＯＲＨＥＰＡＴＩＣＣＡＮＣＥＲＸｉａＳｕｉｓｈｅｎｇ夏穗生（ＩｎｓｔｉｔｕｔｅｏｆＯｒｇａｎＴｒａｎｓｐｌａｎｔａｔｉｏｎ，ＴｏｎｇｊｉＭｅｄｉｃａｌＵｎｉｖｅｒｓｉｔｙ，Ｗｕｈａｎ４３００３０）Ａｂｓｔｒａ...     

肝移植在结直肠癌肝转移中的价值

结直肠癌是全球范围内发病率和死亡率均高的恶性肿瘤之一,早期容易发生转移,而肝脏恰是结直肠癌远处转移的最常见器官.随着肝移植技术的发展与进步,不可切除性结直肠癌肝转移患者获得了长期生存的新机遇.近年来,挪威奥斯陆大学医院在肝移植治疗不可切除性结直肠癌肝转移的领域中取得了一系列巨大突破,引起了世界各地学者的广泛关注.随后,...     

肝癌肝移植术后复发转移的影像诊断

目的 探索肝癌肝移植术后复发转移的影像学诊断方法 .方法 对18例接受肝脏移植的肝癌患者,术后定期行肝脏B超及CT、胸部X-Ray、全身骨扫描(ECT)检查,同时定期监测AFP定量变化情况,并对上述各种影像学检查方法 对复发转移的诊断价值作出评价.结果 12例患者术后出现肝内复发和(或)肝外转移,其中肝内复发7例,肺转移5例,骨转移3例,脑、肾转移各1例.全部复发转移病灶均被B超、CT、X-Ray或ECT及时诊断.结论 B超、CT、X-Ray、ECT检查手段并结合病史资料及AFP定量分析,可以对肝癌肝移植术后复发转移作出及时诊断.     

Our experience with resection of primary and secondary liver tumours

The authors retrospectively analyse the results achieved in recent years by surgical treatment of 103 malignant primary or secondary liver cancers: (Three patients have been operated on twice at different times for recurrence.) 23 hepatic resections were performed for benign lesions. The operative mortality is very low, the incidence of postoperative complications is minimal, and the survival up to 8 years is rather satisfactory. In all cases we used Ton That Tung's surgical technique, that is, "finger fracture with intraparenchymal ligature of the vasculobiliary pedicles."     

Angiosarcoma of the head and neck with intra-oral presentation. A clinico-pathological study of four cases

Angiosarcoma of the head and neck is a rare malignant tumour that most commonly involves the skin and subcutis, particularly of the scalp. It has been reported in intra-oral locations very rarely. This study reports on the clinico-pathological features of four such cases, in elderly patients and manifesting an aggressive course. All patients were admitted for rapidly enlarging masses involving the hard palate, alveolar crest and retromolar trigone and displaying bone destruction in three cases. Morphologically, three cases were composed by bundles of spindle cells admixed with variably sized abortive vascular channels which only showed slit-like spaces separating large clusters of epithelioid cells. In all instances, intra-cytoplasmic vacuoles containing intact or fragmented red blood cells were distinctly evident. All neoplasms showed consistent CD 31 immunoreactivity and variable degrees of CD 34 and Factor VIII related antigen positivity and were responsible for the death of the patients, for local progression or lung metastases, within 6 months from the original diagnosis. Due to their rarity, angiosarcomas with intra-oral presentation may be diagnosed with difficulty, especially on small incisional biopsies, and their differentiation from spindle cell carcinoma, malignant melanoma, anaplastic lymphoma, malignant myoepithelioma and other sarcomas that more commonly arise at this site should be based on accurate immunohistochemical characterisation.     

原发性肝癌的非手术治疗进展

尽管手术切除及肝移植治疗可以明显延长肝癌病人的生存期,但是由于疾病发现时多属晚期,无法行手术治疗。因此,非手术治疗在原发性肝癌的治疗中起着举足轻重的作用。近年来,原发性肝癌的介入治疗、放疗、中药治疗、物理治疗等得到了不断的发展。     

肝移植术后的营养治疗

目的探讨肝移植术后的营养治疗方法。方法对11例肝移植病人术后的营养治疗方法和营养状况进行回顾性分析。术后1～3天采用全肠外营养(TPN)，辅以人白蛋白、血浆；术后4—5天肠内营养(EN)结合肠外营养(PN)；术后6～10天逐渐过渡到全肠内营养；术后12～18天完全经口进食。术后常规使用重组人生长激素rhGH4～7天。结果除2例病人分别死于脑出血、呼吸衰竭外，余9例恢复顺利。结论适当的营养治疗有利于肝移植病人的术后恢复。     

Surgical treatment for hepatocellular carcinoma in cirrhotic patients. Guide to the selection and decision-making process in a context of multimodal strategy

Hepatocellular carcinoma (HCC) is the fifth most frequent malignant tumour and the third leading cause of death due to cancer worldwide [1]. Surgical treatment is the only long-term curative therapy. But the resection rate remains low in cirrhotic patients due to contraindications imposed mainly by hepatic insufficiency and excessively advanced tumoral stages. In recent years, however, due to the extended use of screening programmes in high-risk patients, tumours are smaller at presentation, making treatments easier. In the current context of shortage of organs for transplantation, surgical resection remains the best available treatment option for most patients with HCC in cirrhotic livers. Despite the encouraging results reported by several groups in terms of overall survival, the high recurrence rate is still an unsolved problem. Recently, a large, randomised, placebo-controlled trial has shown that a multikinase inhibitor targeting Ras-kinase and VEGFR-2, sorafenib, improves survival of patients with advanced HCC. Sorafenib was approved by regulatory agencies during 2007 and is likely to become the new standard therapy for HCC patients with advanced disease.     

A contemporary systematic review on liver transplantation for unresectable liver metastases of colorectal cancer

The 5-year overall survival rate of a patient with unresectable metastatic colorectal cancer is poor at approximately 14%. Similarly, historical data on liver transplantation (LT) in those with colorectal liver metastases (CRLM) showed poor outcomes, with 5-year survival rates between 12% and 21%. More recently, limited data have shown improved outcomes in select patients with 5-year overall survival rates of approximately 60%. Despite these reported survival improvements, there is no significant improvement in disease-free survival. Given the uncertain benefit with this therapeutic approach and a renewed investigational interest, we aimed to conduct a contemporary systematic review on LT for CRLM. A systematic review of the literature was performed according to the preferred reporting items for systematic reviews and meta-analysis statement. English articles reporting on data regarding LT for CRLM were identified through the MEDLINE (via PubMed), Cochrane Library, and ClinicalTrials.gov databases (last search date: December 16th, 2021) by 2 researchers independently. A total of 58 studies (45 published and 13 ongoing) were included. Although early retrospective studies suggest the possibility that some carefully selected patients may benefit from LT, there is minimal prospective data on the topic and LT remains exploratory in the setting of CRLM. Additionally, several other challenges, such as the limited availability of deceased donor organs and defining appropriate selection criteria, remain when considering the implementation of LT for these patients. Further evidence from ongoing prospective trials is needed to determine if and to what extent there is a role for LT in patients with surgically unresectable CRLM.     

Liver transplantation for unresectable malignancies: Beyond hepatocellular carcinoma

Indications for liver transplantation have expanded over the past few decades owing to improved outcomes and better understanding of underlying pathologies. In particular, there has been a growing interest in the field of transplant oncology in recent years that has led to considerable developments which have pushed the boundaries of malignant indications for liver transplantation beyond hepatocellular carcinoma (HCC). In this article, we review and summarise the published evidence for liver transplantation in non-HCC primary and metastatic liver malignancies and highlight ongoing clinical trials that address unresolved questions therein. We also examine the current technical, immunological and oncological challenges that face liver transplantation in this growing field and explore potential approaches to overcome these barriers.     

Radiation-induced liver disease in three-dimensional conformal radiation therapy for primary liver carcinoma: the risk factors and hepatic radiation tolerance

PURPOSE: To identify risk factors relevant to radiation-induced liver disease (RILD) and to determine the hepatic tolerance to radiation. METHODS AND MATERIALS: The data of 109 primary liver carcinomas (PLC) treated with hypofractionated three-dimensional conformal radiation therapy (3D-CRT) were analyzed. Seventeen patients were diagnosed with RILD and 13 of 17 died of it. RESULTS: The risk factors for RILD were late T stage, large gross tumor volume, presence of portal vein thrombosis, association with Child-Pugh Grade B cirrhosis, and acute hepatic toxicity. Multivariate analyses demonstrated that the severity of hepatic cirrhosis was a unique independent predictor. For Child-Pugh Grade A patients, the hepatic radiation tolerance was as follows: (1) Mean dose to normal liver (MDTNL) of 23 Gy was tolerable. (2) For cumulative dose-volume histogram, the tolerable volume percentages would be less than: V5 of 86%, V10 of 68%, V15 of 59%, V20 of 49%, V25 of 35%, V30 of 28%, V35 of 25%, and V40 of 20%. (3) Tolerable MDTNL could be estimated by MDTNL (Gy) = -1.686 + 0.023 * normal liver volume (cm3). CONCLUSION: The predominant risk factor for RILD was the severity of hepatic cirrhosis. The hepatic tolerance to radiation could be estimated by dosimetric parameters.     

Cryoprobe as a "handle" for resection of metastatic liver tumors

Resection of metastatic liver tumors can be a difficult and risky procedure. Using a cryoprobe as a "handle" can greatly facilitate resection by providing a taut surface for transection and improving visualization of ductal and vascular structures. In addition, this technique may decrease the risk of contaminating surrounding tissues with cancer cells, and may inhibit tumor recurrence within the margins of resection.     

肝胆恶性肿瘤家族遗传特点的研究及其临床意义

目的分析肝胆恶性肿瘤的家族遗传特点,确定高危人群,提高早期诊断率和手术切除率,改善预后。方法将1993年1月至2002年12月收治的胆道恶性肿瘤患者50例和原发性肝癌患者100例列为观察组,胆石症患者100例和乙型肝炎并肝硬化患者100例列为对照组。通过随访统计观察组家族成员中恶性肿瘤的发病情况。结果50例胆道恶性肿瘤患者的血缘亲属中发生恶性肿瘤1例,非血缘家属中无恶性肿瘤发生,家族中恶性肿瘤发病率为2.0%(1/50)。100例原发性肝癌患者中,血缘亲属发生恶性肿瘤22例,发生率为22.0%(22/100)。其中原发性肝癌20例,发病率为20.0%(20/100)。非血缘家属中无恶性肿瘤发生。100例胆石症和100例乙肝并肝硬化患者的血缘亲属及非血缘家属均无恶性肿瘤发生,家族发病率0。结论胆道恶性肿瘤患者家族成员之间未发现明显的家族遗传关系,单纯的家族遗传因素对胆管癌发病的影响并不大。原发性肝癌的发病有明显的家族遗传性,其一级亲属中合并乙肝(尤其合并小三阳)和肝硬化的男性成员,应列为原发性肝癌发病的极高危人群,必须严密观察,以提高早期诊断率和手术切除率,改善预后。