肝癌术后复发原因的探讨

OBJECTIVE: To analyze the causes of recurrence of hepatocellular carcinoma (HCC) after resection according to pathologic findings of the resected primary tumor and angiographic features of the recurrent tumor. METHODS: In this series, 142 cases with recurrent HCC were analyzed with respect to (1) size, number, gross and histologic findings of the primary tumor, (2) time when recurrence occurred, (3) size, number, blood supply, staining property of, and deposition of lipiodol oil in the recurrent tumor. Following angiography, arterial embolization was performed. RESULTS: In 101 of the 142(71.1%) cases, the primary tumor was > 5 cm in diameter, and in 41 cases (28.9%) it was < 5 cm. In 67.7% of the cases, the capsule of the primary tumor was incomplete or absent. In 47 cases (33.1%), satellite tumor nodules were seen during operation but they were seen on pathologic sections in 94 cases (66.2%). Tumor thrombus was present in the portal vein in 26 (18.3%) and 121 cases (85.2%) during operation and on pathologic examination, respectively. In the majority of the cases (99/142), recurrence occurred within 6 months after operation. The recurrent foci consisted of multiple tumor nodules of < 5 cm in 68.3% of the cases. On angiography, the recurrent tumors were rich in blood supply with good deposition of lipiodol. CONCLUSION: Recurrence is apt to occur in HCC patients with large (> 5 cm) primary tumor which has incomplete or no capsule, satellite tumor nodules and portal vein tumor thrombus. It is suggested to perform angiography 1-2 months after surgery to detect early recurrence and, if confirmed, the patients can be treated by transcatheter arterial chemo-embolization.     

肝癌术后复发

Objective:To analyze pest-surgical recurrence of hepatocellular carcinoma (HHC) according to pathologic findings, primary tumor and angiographic features of the recurrent tumor. Methods:In this series, 100 cases of recurrent HCC were analyzed in following aspects: (1) size, tumor nodular numbers, gross and histologic findings of the primary tumor; (2) post-surgical recurrent time; (3) size, tumor nodular numbers, blood supply, staining property, and accumulation of lipiodol oil in the recurrent tumor. Following angiography, arterial chemoembolization was performed. Results:In the primary tumor, single nodules were seen in 80 cases, multiple nodules in 16 cases and multiple fused nodules in 4 cases. All tumors were classified as: trabecular type, 65 eases; compact type, 12; sclerotic type, 2 cases; mixed type, 15 cases and cholangiocareinoma type, 6 cases. 38 cases had incomplete or no capsule. Satellite tumor nodules were grossly identified during operation in 33 cases, but were proven microscopically in 66 cases. Tumor thrombi of portal vein was noted in 18 cases during oeration, but 85 cases in histopathological sections. The recurrent tumors were diagnosed post surgically within 6 months in 67 cases, 6-12 months in 15 cases and after 12 months in 18 cases respectively. On angiography, 67% recurrent tumors was rich in blood supply and with abundant accumulation of lipiodol after embolization. Conclusion:The post-surgical recurrence rate of the HCC patients with massive size, incomplete or no capsule, satellite tumor nodules and portal vein tumor thrombus was high. The patients shoud receive angiography in 1-2 months after surgery in order to detect early recurrence and, if confirmed, the patients may be treated by transcatheter arterial chemoembolization     

肝癌术后预防性肝动脉化疗栓塞对延缓复发的意义

[目的]了解预防性肝动脉化疗栓塞术(TACE)在延缓肝癌手术后复发方面的作用.[方法]对823例行根治性切除并经病理证实为肝细胞癌患者进行随访分析.其中126例患者手术后行预防性TACE,将可能影响原发性肝癌术后复发的观察指标包括性别、年龄、术前AFP、有无癌栓、手术切缘、手术前肿瘤是否破裂、肿瘤大小、肿瘤有无子灶、肿瘤包膜情况、手术后有无行预防性TACE等,用Cox模型分析各因素与复发时间之间的关系.所有数据经SAS6.12和SPSS统计软件处理分析.[结果]年龄小、有癌栓、手术前肿瘤有破裂、肿瘤体积大和肿瘤周围有子灶等因素使肝癌手术后复发时间提前,保证较大手术切缘距离和手术后行预防性TACE可延缓肝癌手术后复发.预防性TACE可明显降低肝癌患者术后2年的复发率.[结论]对有早期复发病理学征象的肝癌患者行预防性TACE治疗可能延缓术后肿瘤复发.     

A pre-operative chemoembolization therapy using lipiodol, cisplatin and gelatin sponge for hepatocellular carcinoma

The significance of pre-operative transcatheter arterial chemoembolization therapy using lipiodol, cisplatin and gelatin sponge (Gelfoam) for the prevention of the recurrence of hepatocellular carcinoma (HCC) was evaluated. On the 103 patients who underwent radical operations for HCC with a tumor size less than 10 cm, 52 patients received no pre-operative therapy (group C), and 51 patients received pre-operative chemoembolization using lipiodol, a chemotherapeutic agent and Gelfoam. Of these 51 patients, 37 patients received a combination of lipiodol, cisplatin and Gelfoam (group A), while the remaining 14 patients received lipiodol, adriamycin and Gelfoam (group B). The disease-free survival rates after surgery were compared between group A, group B and group C. The 2-year disease-free survival rates in group A, group B and group C were 72%, 46% and 54%, respectively. These rates therefore suggest that pre-operative chemoembolization using lipiodol, cisplatin and Gelfoam is a useful method to prevent the recurrence of HCC after surgery.     

血管造影在肝细胞癌术后复发诊治中的意义

目的:探讨肝细胞肝癌术后复发血管造影的影像学表现、介入治疗及指导临床的意义。方法:回顾性分析112例原发性肝细胞癌手术切除后复发的肝动脉造影表现和化疗栓塞治疗的结果。结果:造影表现归纳为三种类型:I型(边缘复发型)23例,占20.5%;II型(肝内播散型)81例,占72.3%;III型(隐匿复发型)8例,占7.1%。造影表现特点:血供相对不丰富,肿瘤结节染色浅淡,病灶常呈多发性;小病灶(直径<2.0cm)多见。结论:血管造影对于指导术后复发的肝细胞肝癌的综合治疗具有十分重要的意义。     

肝癌术后肝动脉化疗栓塞治疗患者肿瘤复发的影响因素分析

目的 探讨影响肝癌术后经导管肝动脉化疗栓塞治疗(TACE)患者肿瘤复发的危险因素.方法 选择并收集200例肝癌患者的年龄、性别等一般人口学特征和临床特征资料并对患者进行随访追踪,采用Logistic逐步回归分析法分析肿瘤复发的影响因素.结果 在200例患者中130例有肿瘤复发,占65.0％.Logistic逐步回归分析结果显示,血管癌栓(OR=3.796;95％CI:1.871～7.702)、侵透肝被膜(OR=3.340;95％CI:1.067～10.451)、肝硬化(OR=2.790;95％CI:1.771～4.396)、包膜完整性(OR=2.048;95％CI:1.273～3.298)和最大癌结节直径(OR=1.739;95％CI:1.014～2.980)是肝癌术后TACE治疗患者肿瘤复发的危险因素.结论 肝癌术后TACE治疗患者的肿瘤复发率较高,术前有无血管癌栓、侵透肝被膜和肝硬化,包膜是否完整,以及肿瘤的直径等均会影响肿瘤复发,临床需要加强患者术后复诊和康复治疗.     

肝细胞癌周围微小病灶的影像诊断与介入治疗

目的:探讨肝细胞癌病灶周围微小病灶的影像诊断及介入治疗效果。方法:由两名有经验的放射学医生共同回顾性分析80例肝细胞癌病灶周围微小病灶的螺旋CT及血管造影表现,并达成一致意见。所有病例均行经肝动脉化疗栓塞治疗。结果:80例肝癌患者经螺旋CT或/和DSA造影发现病灶周围微小病灶者37例,其中微小病灶只分布于主灶周围1cm范围内者21例。经肝动脉化疗栓塞治疗可栓塞肝细胞癌周围的微小病灶。结论:肝细胞癌病灶周围的微小病灶存在较为广泛,术前准确诊断有利于指导经肝动脉化疗栓塞治疗。     

根据大肝癌的血供特点确定介入治疗的碘油剂量

目的　探讨介入治疗时根据CT显示大肝癌血供的情况 ,确定个体较准确的碘油剂量的可行性。方法　对 10 0例大肝癌 (最大直径 >8cm)行多排螺旋CT 3期薄层扫描 ,根据血供特点分为 4型 :多血供、少血供、混合性血供和明显动静脉瘘。根据肿瘤大小和血供特点确定相应超液化碘油的剂量。经肝动脉行化疗栓塞 (TACE)时随机分为两组 ,第 1组按照术前制定剂量并根据实际情况以充满为止 ;第 2组仅以肿瘤最大直径为标准。观察两组肿瘤内碘油充填情况 ,比较两组符合率及有效率。结果第 1组和第 2组符合率分别为 82 .0 %和 36 .0 % ,有效率分别为 84 .0 %和 4 6 .0 % ,第 1组显著高于第 2组 ,差异具有非常显著性 (P <0 .0 1)。结论　根据CT图像对大肝癌肿瘤血供进行分类 ,确定灌注碘油的剂量 ,并在治疗中进行适当调整 ,可取得较好疗效。     

原发性肝癌根治切除后介入治疗对复发防治的疗效评价

目的 探讨原发性肝癌根治切除术后肝动脉介入综合治疗对肝昨发的防治效果。方法 根治术后定期复查肝功能、甲胎蛋白（ＡＦＰ）、Ｂ超、胸片等,于术后２个月按Ｓｅｌｄｉｎｇｅｒ法行肝动脉造影或碘化油ＣＴ检查,根据有无残癌分为两组;无残癌者为预防组,有残癌者为治疗组。预防组术后２个月和５个月分别行预防量的肝动脉化疗栓塞治疗,以观察复发率和生存期,治疗组按常规量行肝动脉化疗栓塞治疗,每２个月得１次以观察生存期。     

肝癌肝动脉栓塞化疗术并发碘油肺栓塞的临床观察

探讨肝癌肝动脉栓塞化疗术并发碘油肺栓塞的发病机制、临床表现、治疗方法及预防措施。分析肝癌行TACE术后发生碘油肺栓塞7例患者的术前肝脏CT、术中DSA检查、术中所用的碘油量及化疗药物剂量、术中术后的临床表现、辅助检查及临床治疗情况。患者出现不同程度的咳嗽、咯血、呼吸困难和低氧血症,胸片可见片状密度增高影。给予吸氧、扩张支气管、必要时呼吸机辅助呼吸及其他支持治疗后好转。随访观察20d～2个月,复查胸片正常。7例病例病灶直径约>10cm,存在肝动脉-肝静脉瘘的5例,碘油用量>20mL的5例。初步研究结果提示,碘油肺栓塞常发生在巨块型肝癌,且多存在肝动脉-肝静脉瘘,碘油用量多>20mL,术中正确处理可减少此类并发症的发生。     

RESULTS OF HEPATECTOMY FOR 600 CASES WITH PRIMARY LIVER CANCER

ＲＥＳＵＬＴＳＯＦ　ＨＥＰＡＴＥＣＴＯＭＹＦＯＲ６００ＣＡＳＥＳＷＩＴＨＰＲＩＭＡＲＹＬＩＶＥＲＣＡＮＣＥＲＬｉＧｕｏｈｕｉ李国辉；ＬｉＪｉｎｑｉｎｇ李锦清；Ｚｈａｎｇｙａｑｉ张亚奇；Ｙｕａｎｙｕｎｆｅｉ元云飞；ＣｈｅｎＭｉｎｓｈａｎ陈敏山；ＧｕｏＲ...     

Chemoembolization therapy with cisplatin.lipiodol (CDDP.lipiodol) in primary liver cancer--with special reference to hepatocellular carcinoma

From Jan., 1985 to Mar., 1986 thirty-six patients with primary liver cancer received transcatheter arterial chemoembolization therapy with Cisplatin (100 mg) blended into Lipiodol (5 ml) and simple embolization therapy with Gelfoam particles. Thirty-three cases out of 36 had hepatocellular carcinoma, one had hepatoblastoma and one had adenocarcinoma. Ten (31%) out of 32 had hepatocellular carcinoma, and showed objective tumor reduction greater than 50% (partial response) regarding the main tumor. Of the 33 there was one sudden death due to intracerebral hemorrhage. Only two out of 25 cases with daughter nodules showed slight reduction. Almost all cases with daughter nodules showed no response to chemoembolization therapy. Five patients died after chemoembolization therapy during the fifteen-month study period. Two patients died of liver abscess or cholecystitis and surrounding abscess, one died of intracerebral hemorrhage, one died of hepatic failure and the remaining case was one of tumor death.     

影响原发性肝癌LP—TAE疗效的因素分析

1988年4月至1990年12月,以碘油—抗癌剂混悬液及明胶海绵碎粒栓塞肝癌的供血动脉(Lp—TAE)治疗原发性肝癌178例,累积生存率(Cumulative Survival Rate)分别是一年67.97％和二年43.51％。认为LP—TAE是肝癌的最好姑息手段。如何进一步提高疗效使姑息变成治愈?作者对178例患者的肝动脉造影,CT扫描片,手术病理标本等资料进行了对比分析,认为碘油抗癌药物混悬液沉积不充分是病灶未能完全被消灭的关键。影响药物充分沉积的主要因素是:①肝癌乏病理血管;②药量不足;③癌灶内严重的动静脉分流;④没有用明胶海绵栓塞或栓塞不充分;⑤肝动脉外供血;⑥混悬液制作不良等。强调了首次LP—TAE的重要性。     

肝动脉化疗栓塞序贯微波消融治疗初治大肝癌1年内复发的影响因素分析

目的:研究并探讨经肝动脉化疗栓塞(TACE)联合微波消融(MWA)治疗大肝癌(含巨块型肝癌)1年内局部复发的影响因素。方法:回顾性分析2013年1月至2016年6月151例行TACE联合WMA治疗的初治大肝癌患者为研究对象,收集患者治疗前后住院资料及随访资料,通过单因素分析及Logistic 回归分析探求TACE联合MWA治疗大肝癌1年内局部复发的影响因素。结果:151例患者平均行TACE治疗(1.48±0.43)次、WMA治疗 (1.23±0.16)次;联合治疗1个月后,客观缓解率(ORR) 、疾病控制率(DCR)分别为80.8%、92.7%;治疗1年内局部复发率为45.7%;复发组与未复发组在瘤体最大直径、合并门静脉癌栓(PVTT)、肝门淋巴结转移、术前甲胎蛋白(AFP)水平、毗邻危险区域、病毒载量、靶向治疗7方面差异显著(P＜0.05)。多因素分析显示:瘤体最大直径(OR7.5~10 cm=3.935;OR＞10 cm=6.379)、术前合并门静脉癌栓(OR=7.877)、术前AFP≥400 ng/ml(OR=3.411)是TACE联合WMA治疗大肝癌术后1年内复发的独立危险因素(P均＜0.05),术后服用索拉菲尼则是复发的独立保护因素(OR=0.119)(P＜0.05)。结论:术前AFP≥400 ng/ml、瘤体最大直径超过7.5 cm、合并门静脉癌栓是TACE联合WMA治疗大肝癌短期内复发的预测因子,而术后联合靶向治疗有助于降低短期复发率。     

Combination therapy with radiofrequency ablation and transcatheter chemoembolization for the treatment of hepatocellular carcinoma: Short-term recurrences and survival

To evaluate short-term clinical results of radiofrequency (RF) ablation combined with transcatheter chemoembolization for the treatment of hepatocellular carcinoma (HCC) and to identify factors having influence on early intrahepatic recurrence. Sixty-four patients with 92 HCC lesions underwent RF ablation within 2 weeks after chemoembolization. The maximum tumor size was small (5 cm) were significantly linked with higher probability of early intrahepatic recurrence. In the multivariate analysis, tumor number was the only independent factor having significant impact on early intrahepatic recurrence. The estimated 1- and 2-year survival rates were 100% and 93%, respectively. This combined therapy showed good early therapeutic effects on treated lesions and survival. Tumor number and maximum tumor size are important factors for early intrahepatic recurrence.     

原发性肝癌切除术后预后因素的Cox模型分析

目的 探讨影响原发性肝癌切除术后预后因素,为其临床综合治疗及判断预后提供依据。方法 回顾性分析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,对可能影响预后的各种因素进行单因素分析,将单因素分析中可能影响预后的指标依次引入Cox比例风险模型进行多因素分析。结果 全组1、3、5年复发率分别为39.3％、68.3%和82.8%,总生存率分别为76.6%、39.3%和24.1%。单因素分析显示,年龄、肿瘤包膜形成、肿瘤包膜浸润、门脉癌栓、微血管浸润、肿瘤直径和肿瘤早期复发对预后有影响(P<0.05)。多因素分析表明肿瘤早期复发、门脉癌栓、微血管浸润为影响肝癌预后的独立因素。结论 原发性肝细胞癌的预后是由多种因素决定的,肿瘤早期复发、门脉癌栓、微血管浸润是影响其预后的最主要因素。及早发现、早期规范的治疗是提高肝癌患者预后的关键。     

Angiography effectively supports the diagnosis of hepatic metastases in medullary thyroid carcinoma

BACKGROUND: Medullary thyroid carcinoma (MTC) belongs in the group of neuroendocrine tumors with early lymphatic and hepatic dissemination. A high rate of undetectable metastases is hypothesized to be responsible for the frequent mismatch between the apparent relatively small tumor burden and the elevated plasma tumor marker level. METHODS: Thirty-six MTC patients with residual/recurrent biochemical signs (elevated basal calcitonin level) and/or characteristic general symptoms (diarrhea and/or flushing) were systematically examined by conventional radiology, whole-body 18F-deoxyglucose positron emission tomography (PET), dynamic liver computed tomography and magnetic resonance imaging, and hepatic angiography. RESULTS: Conventional diagnostic imaging revealed lymph node (LN) involvement in the cervical, mediastinal, supraclavicular, and axillary regions (16 cases), and multiple pulmonary (3 cases), bony (1 solitary and 1 multiple case), and breast (1 case) metastases. (18)F-deoxyglucose PET identified all these extralymphatic metastatic lesions (except 2 cases with multiple pulmonary metastases), and also supradiaphragmatic LN involvement in 34 (94%) patients. In 32 (89%) cases, multiple small (generally < or = 1 cm) hypervascular, hepatic metastases undetectable by other imaging methods were localized angiographically. Of the 23 original pathologic specimens investigated, 18 (78%) exhibited LN involvement. The smallest primary tumor in patients with hepatic metastases was 1 cm. CONCLUSIONS: Hepatic angiography is recommended for primary staging in MTC patients with a primary tumor measuring 1 cm or larger, and/or pathologically proven LN involvement, and also during restaging for suspected recurrences to avoid unnecessary extensive surgical LN dissection in the neck and mediastinum.     

肝癌的肝外动脉供血及其介入治疗

目的 探讨肝癌的肝外动脉供血规律、插管技术及介入治疗。方法 分析62例肝癌患者78条肝外动脉供血特征,对肝外动脉供血支行超选择插管,并同时进行肝动脉系统及肝外动脉供血支的双动脉化疗栓塞术。结果 肝外动脉供血占肝癌患者的43．1％,肝外动脉供血与肿瘤部位、大小密切相关;RH、Cobra、SP管配合使用,肝外动脉供血支插管成功率为71．8％。治疗后1个月复查,CT显示肿瘤缩小,碘油沉积致密完全。结论 肝癌有丰富的肝外动脉供血,对具有肝外动脉供血的肝癌患者采取双动脉内化疗栓塞是可行、必要和有效的。     

具有乳头状核特征的非浸润性甲状腺滤泡性肿瘤临床病理特征分析

  目的:  探讨具有乳头状核特征的非浸润性甲状腺滤泡性肿瘤（non-invasive follicular thyroid neoplasm with papillary-like nu-clear features,NIFTP）的临床病理学特征。  方法:  回顾性分析2012年1月至2017年12月蚌埠医学院第一附属医院7例NIFTP患者的临床表现、组织形态学、免疫组织化学、分子遗传和预后特征,并复习相关文献。  结果:  7例NIFTP患者中,男性3例,女性4例,年龄36~54岁,中位年龄50岁;肿瘤直径0.2~3.0 cm,中位直径1.2 cm。单发结节4例,双发结节2例,多发结节1例。7例形态学表现为包膜完整、边界清晰,无血管和包膜浸润;肿瘤细胞核大、拥挤,部分可见核沟、核内假包涵体及毛玻璃样核,具有甲状腺乳头状癌（papillary thyroid carcinoma,PTC）的核特征。免疫组织化学缺乏特异性表达,诊断价值有限,Ki-67增殖指数低。荧光定量PCR检测KRAS和NRAS基因突变2例,均无BRAF V600E突变。5例随访21~74个月,无复发和转移,2例失访。  结论:  NIFTP是一种极低度恶性潜能的甲状腺交界性肿瘤,具有特定形态学表现和惰性生物学行为,RAS基因突变检测有助于诊断。      

Treatment outcomes for hepatocellular carcinoma using chemoembolization in combination with other therapies

BACKGROUND: Although transarterial chemoembolization (TACE) improves survival in patients with hepatocellular carcinoma (HCC), it is not known if TACE combined with other treatments is beneficial. Aim: To evaluate the evidence for improved outcomes in HCC with a multimodal treatment approach involving TACE. METHOD: PubMed search for all cohort and randomized trials (n=84) evaluating TACE combined with other therapies; meta-analysis performed where appropriate. RESULTS: A meta-analysis involving 4 RCTs showed a significant decrease in mortality favouring combination treatment (TACE plus percutaneous ablation) compared to monotherapy in patients with either small (<3cm) or large HCC nodules (>3cm) (OR, 0.534; 95% CI, 0.288-0.990; p=0.046). TACE combined with local radiotherapy improved survival in patients with tumour thrombosis of the portal vein in 7 non-randomized studies. Two RCTs and 13 non-randomized studies showed that TACE prior to hepatic resection does not improve survival nor tumour recurrence. Conversely, 2 RCTs and 5 comparative studies showed that transarterial injection of chemotherapeutic drugs mixed with lipiodol (TOCE) following hepatectomy confers survival benefit and less tumour recurrence. TACE before liver transplantation is safe and reduces drop-out rate from the waiting list, but there is no current evidence of improvement in subsequent survival or recurrence rate. CONCLUSIONS: A combined approach involving TACE and percutaneous ablation improves survival. Adjuvant TOCE improves outcome after hepatectomy. TACE is useful to control tumours burden while on the waiting list for OLT. Multimodal treatment seems to be the best way to optimize TACE outcomes in HCC.