恩度肝动脉灌注联合肝动脉化疗栓塞治疗中晚期原发性肝癌的生存分析

目的探讨恩度肝动脉灌注联合经导管肝动脉化疗栓塞治疗中晚期肝癌的疗效。方法选取2009年9月-2011年6月天津医科大学附属石油医院收治的76例中晚期肝癌患者。其中44例给予恩度肝动脉灌注联合经导管肝动脉化疗栓塞治疗,其余32例作为对照组,仅行经导管肝动脉化疗栓塞治疗。治疗后,所有患者不定期行CT或磁共振成像(MRI)检查,观察肿瘤复发或转移情况以及有无肿瘤新生血管形成。计数资料组间比较采用χ2检验,Kaplan-Meier法绘制生存曲线,Log-rank法分析两组术后生存差异。结果恩度治疗组的治疗有效率(RR)高于对照组(70.45%vs 43.75%),差异有统计学意义(χ2=5.47,P<0.05);疾病控制率(DCR)高于对照组(84.09%vs 56.25%),差异有统计学意义(χ2=7.18,P<0.01);两组中位无进展生存时间(m PFS)分别为9.00个月和5.00个月,差异有统计学意义(P=0.044)。中位生存期(m OS)分别为10.64个月和8.11个月,差异无统计学意义(P=0.448)。结论采用恩度肝动脉灌注联合经导管肝动脉化疗栓塞治疗中晚期肝癌,可明显改善患者近期疗效及PFS,但对总生存期的改善不明显。     

门静脉支架及经动脉药物治疗栓塞联合或未联合血管内植入碘-125粒子条治疗肝癌合并门静脉主干癌栓的比较

目的 比较门静脉支架及经动脉药物治疗栓塞(TACE)联合或未联合血管内植入碘-125(125I)粒子条治疗原发性肝癌伴门静脉主干癌栓的疗效.方法 对106例(男94例,女12例,平均年龄53.23岁)在我院接受TACE治疗的原发性肝癌合并门静脉主干癌栓患者的资料进行回顾性分析,其中56例(A组)在门静脉内植入支架及125I粒子条,余50例(B组)仅在门静脉内植入支架.分别对两组患者的生存期、支架通畅率及相关不良事件进行分析.对治疗前后各测量值的改变采用配对样本t检验,计数资料采用x2检验,用Kaplan-Meier法分析生存时间及支架通畅期.结果 门静脉内植入支架及125I粒子条的技术成功率为100％,无严重相关不良事件发生.两组患者中位生存期分别为335 d(A组)及146 d(B组),P=0.001(P＜0.05)及HR=2.244;两组患者支架的中位通畅期分别为400d (A组)及190d(B组),P=0.005(P＜0.05)及HR=2.479.结论 门静脉支架及TACE联合血管内植入125I粒子条能显著延长原发性肝癌伴门静脉主干癌栓患者的生存期.     

超声引导下经皮肝穿刺注射华蟾素与无水乙醇治疗门静脉癌栓的效果比较

目的对比观察超声引导下经皮肝穿刺注射华蟾素与注射无水乙醇治疗门静脉癌栓的疗效。方法选取2009年10月~(-2)011年12月解放军第九四医院收治的56例肝癌术后复发的门静脉癌栓患者,其中27例行超声引导下经皮肝穿刺华蟾素注射治疗(华蟾素组),29例行超声引导下经皮肝穿刺无水乙醇注射治疗(无水乙醇组)。对比2组患者的临床疗效及生存期,并比较其治疗前后的TBil、ALT、AST水平。计量资料组间比较采用t检验,计数资料组间比较采用χ~2检验,等级资料比较采用Mann-Whitney U检验,生存分析采用Kaplan-Meier法。结果华蟾素组治疗后的有效率为63.0%,无水乙醇组58.6%,2组差异无统计学意义(χ~2=0.111,P0.05);华蟾素组治疗后的TBil、ALT和AST水平均低于无水乙醇组,差异均有统计学意义(t值分别为2.24、2.40、2.39,P值均0.05);华蟾素组6个月、1、2年生存率分别为81.5%、63.0%、29.6%;无水乙醇组分别为82.8%、58.6%、31.0%,2组差异均无统计学意义(χ~2值分别为0.016、0.111、0.013,P值均0.05)。结论超声介入注射华蟾素和注射无水乙醇治疗门静脉癌栓的近期疗效和远期疗效相似,均能起到抑制癌栓生长、延长生存期的作用,但华蟾素介入治疗在保护肝功能方面优于无水乙醇。     

肝动脉灌注化疗栓塞术治疗晚期肝癌的多中心Ⅱ期临床研究

正门静脉癌栓是肝癌重要并发症。来自日本的Nagamatsu H等作了一项前瞻性多中心试验,评估了将顺铂联合5-氟尿嘧啶悬浮在碘油中的肝动脉灌注化疗栓塞术治疗肝癌患者门静脉癌栓的疗效。共纳入52例肝癌门静脉癌栓患者,均接受将顺铂联合5-氟尿嘧啶悬浮在碘油中的肝动脉灌注化疗栓塞术。主要有效终点为无进展生存期,次要终点为总体生存期、肿瘤应答率、安全性和耐受性,并对生存的独立因素进行了评价。研究结果显示,中位无进展生存期和总生存期分别为8.6和27.0个月。10例患     

原发性肝癌合并门静脉癌栓的外科治疗

目的:探讨原发性肝癌合并门静脉癌栓的外科治疗及提高疗效的方法。方法:采用肝叶切除和经门静脉残端或主干切开取癌栓术治疗32例PHC合并PVTT患者,12例术后联合门静脉、肝动脉介入化疗,5例合并门静脉高压联合行断流术、脾切除或脾动脉结扎术。总结其临床资料、治疗方法、术后并发症及疗效预后,并进行统计学分析。结果:①本组病例术中出血量、输血量、肝门阻断次数时间、术后并发症发生率与同期50例单纯肝癌切除组比较无显著性差异(P>0.05)。②术后并发症:9例肝功能不全,3例术后肝断面出血、5例右胸腔积液、2例上消化道出血,1例术后3个月死于肝功能衰竭,其余恢复良好。③疗效与预后:随访26例,1、2、3年生存率分别为50％、34.6％、15.4％;术后化疗、术前肝功能状况对预后有显著影响。结论:肝叶切除和经门静脉残端或主干切开取癌栓是治疗原发性肝癌合并门静脉癌栓最有效的方法,改善术前肝功能及术后联合化疗,对提高生存期意义重大;门静脉取癌栓联合贲门周围血管断流、和/或脾切除、脾动脉结扎术能有效治疗肝癌合并门静脉高压,减少上消化道出血并发症;对于难以切除的PHC合并PVTT应争取行TACE术,仍有二期手术切除的机会。     

经皮经肝动脉,门静脉介入治疗肝癌的临床研究

对３０例原发性肝癌患者在肝动脉化疗栓塞的基础上,联合应用经皮经肝门静脉化疗栓塞。结果治疗后门静脉癌栓消失和缩小２１例,肝癌缩小２３便,术后０．５、１、２年生存率分别为６６．７％、２０％和６．６％。认为经皮经肝动脉及门静脉双重介入治疗肝癌是一种有效可靠的方法。     

门静脉支架联合动脉化学栓塞疗法治疗肝癌合并门静脉主干癌栓

肝癌(HCC)伴有门静脉主干癌栓(MPVTT)预后极差.由被阻塞门静脉供血的正常肝组织缺血,从而损害肝功能并限制了经肝动脉化疗栓塞(TACE)在治疗HCC中的应用.经皮穿刺肝脏门静脉支架植入(PTPVS)可姑息性解除门静脉阻塞.     

经肝动脉化疗栓塞术治疗肝细胞癌合并门静脉癌栓的预后影响因素分析

目的评估肝细胞癌(HCC)合并门静脉癌栓患者经肝动脉化疗栓塞术(TACE)治疗后的效果及影响预后的因素。方法回顾性分析2006年1月-2010年12月第四军医大学西京医院收治的152例行TACE治疗的HCC合并门静脉癌栓患者的临床资料。观察TACE术后肝衰竭、上消化道大出血、栓塞后综合征等发生情况,分析生存期资料与影响预后的因素。Kaplan-Meier法计算累积生存率,采用Log-Rank法进行单因素分析,Cox比例风险模型进行多因素分析。结果患者中位生存时间为5.0(95%可信区间:4.4~5.6)个月,6、12、18个月的累积生存率分别为37%、18%和9%。单因素分析显示肿瘤大小、肿瘤类型、肝两叶累及、远处转移和Child-Pugh分级是HCC合并门静脉癌栓患者行TACE治疗预后的影响因素(χ2值分别为5.108、11.542、6.036、12.319、22.574,P值均0.05);多因素分析显示肿瘤大小、肿瘤类型、远处转移和Child-Pugh分级是影响患者预后的独立危险因素(Wald值分别为11.243、5.021、7.651、25.876,P值均0.05);而HCC合并门静脉癌栓患者发生肝衰竭的唯一影响因素是Child-Pugh分级(P=0.015)。结论在肝功能良好的HCC合并门静脉癌栓患者中,TACE是安全有效的。肿瘤大小、肿瘤类型、远处转移、Child-Pugh分级是影响患者生存的最主要因素,为临床医生选择合适的介入治疗患者提供了有力证据。     

联合应用雷替曲塞及表柔比星经肝动脉化疗栓塞术治疗中晚期原发性肝癌的临床观察

目的：评价雷替曲塞联合表柔比星介入肝动脉灌注化疗栓塞在治疗中晚期原发性肝癌中的疗效。方法选取中国石油天然气集团公司中心医院2011年1月－2013年5月收治的80例不适合手术治疗的中晚期原发性肝癌患者,将其随机分为研究组和对照组,每组40例。研究组给予雷替曲塞联合表柔比星介入下肝动脉灌注化疗栓塞治疗,对照组给予氟尿嘧啶（5－FU）联合表柔比星介入下肝动脉灌注化疗栓塞治疗。以上治疗每4周1次,共进行3～6周期。观察两组的治疗有效率（RR）、疾病控制率（DCR）、中位疾病进展时间、生存率以及甲胎蛋白（AFP）、癌胚抗原（CEA）、转氨酶、胆红素的下降情况。计数资料组间比较采用χ2检验,计量资料组间比较采用 t 检验。结果研究组的 RR 为52．5％,对照组为22．5％,差异均有统计学意义（χ2＝7．680,P ＝0．006）;研究组的 DCR 为87．5％,对照组为60．0％,差异有统计学意义（χ2＝7．813,P ＝0．005）;研究组的中位疾病进展时间为12．2个月,对照组为8．0个月,差异有统计学意义（t ＝5．118,P ＝0．00）;研究组的1、2年生存率分别为为85．0％、60．0％,对照组分别为65．0％、37．5％,差异均有统计学意义（χ2值分别为4．267、4．053,P 值分别为0．039、0．044）;研究组化疗栓塞术后1个月 AFP、转氨酶、胆红素水平下降超过50％的病例数均多于对照组,差异均具有统计学意义（χ2值分别为4．381、4．114、5．000,P 值分别为0．036、0．043、0．025）。结论雷替曲塞联合表柔比星介入肝动脉灌注化疗栓塞对治疗中晚期原发性肝癌有一定价值,值得在临床中推广。     

经肝动脉化疗栓塞术联合沙利度胺或索拉非尼治疗不可切除原发性肝癌的效果比较

目的探讨经肝动脉化疗栓塞术(TACE)联合沙利度胺及TACE联合索拉非尼两种化疗方式对不可切除性原发性肝癌患者的治疗效果。方法收集2012年1月-2013年8月在陕西省核工业215医院进行两种方式治疗的原发性肝癌患者102例作为研究对象,随机分为TACE联合沙利度胺组(49例)和TACE联合索拉非尼组(53例),对其近期疗效、远期疗效、治疗前后相关化验指标变化及不良反应进行评价。计量资料组间比较采用成组t检验,组内比较采用配对t检验,计数资料组间比较采用χ2检验,采用生存曲线对生存数据进行分析,并采用Log-Rank检验进行比较。结果两组在客观缓解率、疾病控制率等近期疗效方面差异均无统计学意义(P值均0.05)。两组患者的2年生存率差异有统计学意义(χ2=4.692,P=0.03)。两组患者总生存时间及中位无疾病进展生存时间差异均有统计学意义(χ2值分别为8.267、6.896,P值分别为0.004、0.009)。两组患者甲胎蛋白及GGT治疗后组间比较差异均有统计学意义(t值分别为2.035、2.843,P值分别为0.038、0.025)。两组患者在恶心呕吐、头晕头痛、皮疹脱屑及血压升高4个不良反应方面的差异均具有统计学意义(P值均0.05)。结论 TACE联合沙利度胺在与TACE联合索拉非尼具有相同近期疗效的同时可提高患者的远期疗效,还可更显著降低甲胎蛋白及GGT水平,然而也具有恶心呕吐及头晕头痛等不良反应发生率高的不足。     

Hepatocellular Carcinoma With Tumor Thrombus Occupying the Right Atrium and Portal Vein: A Case Report and Literature Review

Hepatocellular carcinoma (HCC) patients with tumor thrombus extended through the major hepatic veins and inferior vena cava into the right atrium (RA) are rare, and most cases are considered as the advanced stage with a poor prognosis.We report a case of HCC with a tumor thrombus extending into the RA and a tumor thrombus in the portal vein. A literature search for case reports was performed on PubMed.Compared with the published literature, our case is one of the youngest patients, but with the most advanced HCC that invades both the hepatic inflow and outflow vasculature. For this patient, we resected the tumor thrombus in the RA with the use of cardiopulmonary bypass, and then removed the tumor thrombus in the portal vein and ligated the left branch of portal vein. Because of insufficient remnant liver volume, microwave ablation and transcatheter arterial chemoembolization were performed to control the growth of HCC. The patient survived 6 months after surgery.This case suggests that for patients with extension of HCC into the RA and portal vein, surgery is a useful therapeutic modality, even in case that liver tumor cannot be resected.     

Effective hepatic artery chemoembolization for advanced hepatocellular carcinoma with extensive tumour thrombus through the hepatic vein

BACKGROUND AND AIMS: Advanced hepatocellular carcinoma (HCC) with extensive tumour growth through the hepatic vein still has an extremely poor prognosis, even after cancer chemotherapy and/or transarterial embolization. Although aggressive surgical treatments using extracorporeal circulation and liver transplantation have been performed by some authors, the reported results were still unsatisfactory. In this study, we report the favourable result of hepatic artery chemoembolization and subsequent surgical resection in three patients with advanced HCC with extensive tumour thrombus through the hepatic vein. METHODS AND RESULTS: Three irresectable patients with HCC with extensive tumour thrombus through the hepatic vein underwent hepatic artery chemoembolization with aclarubicin, mitomycin C, lipiodol and/or Gelfoam. After the reduction of tumour extent with hepatic artery chemoembolization, two of the three patients underwent surgical resection. These two patients are still alive at 59 and 21 postoperative months, respectively. In the other case, the extent of the tumour and functional reserve of the liver prevented us from performing surgical resection, but the patient is doing well 62 months after the initial treatment. CONCLUSIONS: Hepatic artery chemoembolization with aclarubicin, mitomycin C, lipiodol and/or Gelfoam might be an effective treatment for irresectable advanced HCC with extensive tumour thrombus into the inferior vena cava or the right atrium through the hepatic vein. Radical surgical resection might be applicable for selected patients without high surgical risk after reducing tumour extent by hepatic artery chemoembolization.     

应用CTA技术和超声评估肝移植术患者术前肝脏血供状态研究*

目的 研究计算机断层扫描血管成像(CTA)和超声检测评估肝移植术患者术前肝脏血管解剖变异和管腔通畅性。方法 2014年5月～2020年5月我院收治的接受肝移植手术患者138例,术前均行腹部三期CT增强扫描、CTA后处理[包括容积再现(VR)和最大密度投影(MIP)等重建和超声检查。分析肝动脉、门静脉、肝静脉和下腔静脉及其侧支循环情况。结果 138例患者中,CTA显示107例(77.5%)肝动脉解剖起源和走行正常(Michels aⅠ型),31例(22.5%)存在肝动脉解剖变异,肝动脉管腔未出现狭窄和异常扩张情况,1例(0.7%)合并脾动脉瘤;136例患者术中肝动脉解剖与术前CTA评估一致;CTA诊断血栓和瘤栓的灵敏度和准确度分别为83.3%和68.6%,而超声检查诊断为58.3%(P<0.05)和60.0%;超声和CTA诊断肝静脉和下腔静脉通畅性的准确率均为99.3%。结论 相对于超声检查,CTA检查可准确评估肝移植术前肝动脉解剖变异情况,对门静脉栓子定性诊断的准确性也较高,且可清晰显示门静脉侧支循环开放情况。     

Surgical treatment and adjuvant chemotherapy in hepatocellular carcinoma patients with advanced vascular involvement

BACKGROUND/AIMS: In advanced hepatocellular carcinoma (HCC) with vascular involvement of major vessels, patients have a poor prognosis after surgical treatment. METHODOLOGY: Patient outcomes after surgical resection and the usefulness of adjuvant chemotherapy were examined in 12 patients with major hepatic vessel involvement who underwent hepatectomy with combined resection of major blood vessels. RESULTS: The main portal vein was resected in 8 patients, the inferior vena cava in 3, hilar bile duct in 2 and hepatic artery in 1. Eleven patients underwent hemihepatectomy and 1 underwent segment 4 and 5 resection. The portal branch was repaired by venoplasty. The vena cava wall was repaired by suture closure. The hepatic artery was replaced by end-to-end anastomosis. The bile duct was repaired by Roux-en-Y hepaticojejunostomy. Although 2 patients had biliary leakage, there were no postoperative complications in 10 patients. The tumor recurrence rate was 83% in the early period and cancer death within 1 year was observed in 6 (50%), while 3 with tumor recurrence survived for more than 2 years and 2 survived without recurrence. In 233 HCC patients who underwent hepatectomy, 10 patients including 2 present cases received adjuvant chemotherapy at the time of tumor recurrence and 2 had complete responses. While in 11 patients receiving chemotherapy without resection, the response rate using Gemcitabine (66%) was higher than that using low dose Cisplatin plus 5-Fluorouracil (22%). CONCLUSIONS: Complete surgical resection combined with main vascular resection could be safely performed in most advanced stage HCC patients and adjuvant chemotherapy in the early period after resection would be necessary, which may achieve longer survival in some patients even in the advanced stage.     

Pseudo-Budd-Chiari syndrome: extrinsic deformity of the intrahepatic inferior vena cava mimicking membranous obstruction

Budd-Chiari syndrome secondary to membranous obstruction of the intrahepatic inferior vena cava is a treatable form of chronic liver disease. I report a patient with portal hypertension in whom distortion of the inferior vena cava by cirrhosis and increased intraabdominal pressure initially suggested this condition. The correct diagnosis was made by obtaining lateral views during inferior vena cavography, which demonstrated a tapered, rather than membranous, obstruction, along with normal hepatic venous anatomy and pressure and markedly increased portal vein pressure during transhepatic puncture with a thin needle. That extrinsic deformity of the inferior vena cava may mimic membranous obstruction has not been emphasized recently. This distinction is important as surgical membranotomy is not indicated in patients with cirrhosis and secondary deformity of the inferior vena cava.     

Congenital absence of the portal vein complicating hepatic tumors

Congenital absence of the portal vein (CAPV) is a rare malformation that is often accompanied by other anomalies such as cardiac and skeletal malformations and/or hepatic tumors. We describe here a case of CAPV complicating hepatic tumors in a 16-year-old Japanese girl. Abdominal ultrasonography revealed a hyperechoic tumor in the liver and dilatation of the portal vein that appeared to be connected directly with the inferior vena cava. Subsequent abdominal computed tomography (CT) revealed tumors and magnetic resonance angiography confirmed that the portal vein entered directly into the inferior vena cava just above the liver. In addition, there was absence of the right portal vein and the left intrahepatic branch except for the presence of left portal vein only within the porta hepatis. These findings led to a diagnosis of CAPV complicated hepatic tumors. Careful monitoring of these hepatic tumors is ongoing due to the possibility of malignant transformation.     

Hepatocellular carcinoma with inferior vena cava and right atrial tumor thrombus: A case report

This is a case report of a 45‐year‐old patient admitted with the symptom of bilateral leg swelling. Ultrasonography revealed a hyperechoic mass in the right lobe of the liver, which invaded the right hepatic vein (RHV) and extended into the inferior vena cava (IVC) and right atrium (RA). Based on the high alpha‐fetoprotein (AFP) level and the ultrasonography findings, the patient was diagnosed as having hepatocellular carcinoma (HCC) with a RHV, IVC, and RA tumor thrombus and secondary Budd–Chiari syndrome (BCS). HCC with a tumor thrombus extending into the IVC and RA has rarely been observed, and as a cause of secondary BCS, this type of HCC has been even more rarely reported.     

Role of hepatic artery in haemodynamics in normal and cirrhotic livers in rats

To examine the degree of influence of the hepatic artery on microcirculation in the liver, microscopic observation of blood flow in the hepatic minute blood vessels and the sinusoids and pressure measurements at key points in hepatic vascular pathways in vivo were performed before and after hepatic artery ligation in normal and cirrhotic rats. In normal rats, portal vein pressure (109 mmH2O) fell 10 mmH2O after hepatic artery ligation, but the pressures of the terminal portal venule, the terminal hepatic venule and the inferior vena cava did not change. In cirrhotic rats, portal vein pressure (206 mmH2O) and terminal portal venule pressure (106 mmH2O) fell 23 and 10 mmH2O after hepatic artery ligation respectively: the pressures in the terminal hepatic venule and the inferior vena cava did not change. These results suggests that the pressure transmitted from the hepatic artery was mostly supplied to the intrahepatic portal vein in normal rats and both to the intrahepatic portal vein and to the sinusoids in cirrhotic rats. In both normal and cirrhotic rats, however, the pressure transmitted from the hepatic artery was about 10 per cent of the initial portal vein pressure, and the blood flow in minute vessels and sinusoids did not change after hepatic artery ligation. Accordingly, it is believed that the hepatic artery plays only a small role in the haemodynamics of the liver in both normal and cirrhotic rats, irrespective of the distribution and manner of the hepatic arterial termination.     

CT动态增强扫描诊断肝窦阻塞综合征的临床价值及意义

目的探讨CT动态增强扫描对肝窦阻塞综合征(HSOS)的诊断价值。方法纳入经活组织检查及影像学确诊的HSOS、布-加综合征(BCS)及肝硬化患者51例,分别利用CT动态增强扫描结果、巴尔的摩标准再次诊断HSOS,对比两者诊断效果。结果 HSOS的典型CT表现包括CT平扫呈肝大、密度减低;增强扫描动脉期可见肝动脉血管增粗扭曲;门静脉期呈"地图状"改变、肝静脉不清、下腔静脉及门静脉呈"晕征"或"轨道征"、下腔静脉肝段扁平等;延迟期强化范围增大。CT对HSOS的诊断敏感性0.857,优于巴尔的摩标性0.500,CT对HSOS诊断特异性0.811,差于巴尔的摩标准0.946。CT与巴尔的摩标准对HSOS的诊断准确率接近,差异无统计学意义(P0.05)。结论早期诊断HSOS时,CT动态增强扫描是巴尔的摩标准的有力补充。