肝动脉和门静脉栓塞化疗联合射频消融治疗原发性肝癌

目的探讨肝动脉栓塞化疗、门静脉栓塞化疗及射频消融治疗不能手术切除的原发性肝癌的临床价值。方法对不能手术切除的56例肝癌患者行肝动脉栓塞化疗联合经皮门静脉栓塞化疗及射频消融综合治疗,并于同期单纯行TACE治疗的病人60例作对照。结果两组病人的肝功能变化差异无显著性意义（均P〉0.05）;两组病人治疗后ATP转阴率差异有显著性意义（P〈0.05）;CR和PR有显著性差异（P〈0.01）;1年及2年生存率差异有显著性意义（P〈0.05）。结论对不能手术切除的肝癌患者行肝动脉栓塞化疗联合经皮门静脉栓塞化疗及射频消融综合治疗能显著提高AFP转阴率、总有效率及生存率,在临床上有较好的应用价值。     

肝细胞癌的非手术治疗

肝细胞癌（HCC）是原发性肝癌的最主要类型。肝切除术可根治 HCC,使患者长期生存,但肝切除术受到一定的限制,主要在于：（1）肿瘤细胞恶性程度高、病情进展快,极易发生播散和转移;（2）HCC 患者多存在严重的肝硬化基础,因为肝功能失代偿而无法手术;（3）大部分肿瘤为多中心发生,很难切除完全。因此,切除率低和复发率高乃是制约手术治疗 HCC 患者的主要障碍。联合应用手术治疗与各种非手术治疗,多种方案的优化组合将成为综合治疗 HCC 患者的优先选择,提高疗效[1,2]。目前,常用的非手术治疗方法主要有肝动脉化疗栓塞（TACE）、局部消融、放射治疗、系统化疗和分子靶向治疗等。     

肝动脉栓塞化疗联合经皮射频消融治疗老年人肝癌

我院2000年2月～2003年2月开展肝动脉栓塞化疗（TACE）联合经皮射频消融（PRFA）治疗不能手术治疗的老年人肝癌的临床研究,以探讨2种方法联合治疗的价值.     

原发性肝癌的介入治疗

肝癌的介入治疗主要包括二部分:经皮血管治疗技术及经皮非血管治疗技术,前者主要包括经肝动脉栓塞化疗术及经肝动脉门静脉结合栓塞化疗术;后者则指在超声(US)、CT、MR引导下经皮穿刺瘤内局部治疗,包括瘤内药物注射与物理损毁治疗。1肝癌的血管内介入治疗肝癌血管内介入治疗的最主要手段为经肝动脉栓塞化疗术。主要适用于以右叶为主或肝内多发病灶以及术后复发而无法手术切除的肝癌。经肝动脉栓塞化疗有以下作用:1阻断肿瘤血液供应,使肿瘤严重缺血坏死而缩小。2提高局部化疗药物浓度,增强抗肿瘤效应,减少化疗药物毒副作用。3破坏肿瘤的血…     

肝动脉插管化疗栓塞联合射频消融对大肝癌疗效评价

目的 探讨经导管肝动脉化疗栓塞(TACE)联合射频消融(RFA)治疗大肝癌的临床应用价值.方法 收集我院2006年4月～2008年7月肝细胞癌患者66例,并将其分为经导管肝动脉化疗栓塞+射频消融组(19例)、经导管肝动脉化疗栓塞组(24例)和射频消融组(23例),并将其疗效进行比较.结果 经导管肝动脉化疗栓塞+射频消融组的肿瘤坏死率达73.68％,明显高于单纯经导管肝动脉化疗栓塞组及单纯射频消融组(分别为50.00％和52.17％,P＜0.01或P＜0.05).局部复发率分别为26.32％、37.50％和30.43％,3组比较差异无统计学意义(P＞0.05).经导管肝动脉化疗栓塞+射频消融组的平均生存期为28.3个月,高于经导管肝动脉化疗栓塞组与单纯射频消融组(分别为13.6个月、21.7个月,P＜0.01或P＜0.05).结论 经导管肝动脉化疗栓塞联合射频消融治疗大肝癌与单纯经导管肝动脉化疗栓塞和单纯射频消融治疗效果相比,可提高肿瘤坏死率,延长患者生存期.     

原发性肝癌的非手术治疗

我国原发性肝癌的治疗已取得显著的进展 ,肝癌切除术是目前根治性治疗的最有效手段 ,也是肝癌患者获得长期生存的最主要途径。然而手术切除在肝癌治疗中的作用也有一定的限度 ,主要表现在 :①肝癌恶性程度高 ,极易发生早期播散和转移 ;②我国原发性肝癌多伴有严重肝硬化 ,往往存在肝功能失代偿 ;③相当部分的原发性肝癌为多中心发生。因此 ,切除率低和复发率高乃是制约肝癌手术治疗的关键。据文献统计 ,能够接受手术切除治疗的肝癌患者仅占 2 0 %左右。对大多数肝癌患者 ,特别是中晚期患者 ,非手术治疗仍不失为重要的治疗方法。目前应用于肝癌的非手术治疗包括以下几个方面。一、肝动脉化疗栓塞肝动脉化疗栓塞术被公认为非手术治疗的首选方法 ,主要适用于不能切除的肝癌 ,特别是以右叶为主 ,或术后复发而无法手术切除者。对于不能根治切除的肝癌 ,经多次肝动脉化疗栓塞治疗后 ,如肿瘤明显缩小 ,应积极争取及时手术切除 ,使患者获得根治的机会。对于可一期根治性切除的肝癌 ,特别是直径小于5ｃｍ单个结节的肿瘤 ,宜积极予以及时手术切除 ,一般可不考虑术前应用肝动脉化疗栓塞。在切除术后辅以肝动脉化疗栓塞为主的综合治疗可清除可能残存的微小病灶并...     

原发性肝癌的治疗决策

原发性肝癌的病因主要是乙肝病毒及丙肝病毒,绝大多数肝癌患者合并有肝硬化.治疗手段的选择取决于肿瘤位置,转移及肝脏储备功能等因素.在合适的患者中,原发性肝癌首选治疗为肝切除术或肝移植.对不可手术的肝癌,则可选择局部消融治疗或肝动脉栓塞化疗.更晚期的患者只能作对症治疗.治疗选择的标准需以临床实验研究为基础.     

肝动脉结扎插管灌注化疗加栓塞联合治疗不能切除的肝癌

原发性肝癌手术切除是唯一有希望治愈的方法,但手术切除率仅17.6％。自1984年以来我院在行肝动脉结扎术的基础上作插管,术后局部灌注化疗加栓塞治疗不能切除的肝癌38例,收到一定的近期疗效。现重点报道和讨论联合化疗和栓塞方法的优点。     

局部治疗手段在结直肠癌肝转移治疗中的价值

结直肠癌肝转移患者全身治疗是标准治疗,应该作为每一种治疗策略的初始,但局部治疗也发挥着重要价值.手术完全切除肝转移灶仍是目前能治愈结直肠癌和胃肠道神经内分泌肿瘤肝转移的最佳方法 .射频消融主要应用于那些不可切除或术后复发的局限性病灶,但受转移灶大小、数量和解剖位置的制约.立体定向放射治疗作为一种非手术的局部治疗是安全、有效的.微波消融、冷冻消融、高能聚焦超声刀、经皮穿刺瘤内注射无水乙醇、肝动脉栓塞或肝动脉化疗栓塞、肝动脉灌注化疗等也是重要的局部治疗手段,在患者的综合治疗中发挥重要作用.本文就以上内容作一综述.     

TACE与超选PSE、RFA联合治疗原发性肝癌合并脾功能亢进的疗效观察

目前,原发性肝癌仍以手术切除为最有效的治疗方法,但部分患者因发现较晚,或身体条件较差,丧失了手术治疗的机会。我们采用经肝动脉插管化学栓塞（TACE）联合超选择性部分脾栓塞（PSE）和射频消融（RFA）联合介入治疗的方式,取得了满意效果。     

局部胰腺癌精确放疗和放化综合治疗

胰腺癌是目前所有肿瘤中预后最差的肿瘤,早期局限性病变5年生存率不足20%。外科治疗水平已经处于平台期,尽管新的治疗药物不断出现,新的治疗技术不断应用,但是胰腺癌的生存并没有得到明显地改善。回顾了局部胰腺癌的治疗现状,阐明精确放疗在局部胰腺癌治疗中的疗效和作用,探讨放疗作为局部胰腺癌治疗选择的可能性,通过开展综合治疗的系列临床研究有可能改善局部胰腺癌患者的生存。     

重视肝癌的立体定向放射消融治疗

肝细胞癌(HCC)是最常见的原发性肝脏恶性肿瘤,手术切除及肝移植被认为是目前HCC可能的治愈方法,但仅30%～40%的患者能够受益。体部立体定向放射消融治疗(SABR)是近几年应用于体部恶性肿瘤治疗的一种新的精确放疗技术,以"少分次、大剂量"改变了传统的剂量分割模式,因其提高了体部恶性肿瘤的局部控制率、延长了总生存时间而受到重视。射波刀(CK)完成的SABR放疗技术具有高精度、无创伤的优点,可完成实时追踪照射(很好地解决了肿瘤的呼吸移动对治疗的影响),获得了理想的治疗有效率和局部无进展生存率、总生存率,同时3级以上放疗毒性反应发生率很低,是一种理想的治疗技术,为进一步提高HCC的临床疗效带来了新的希望。     

Liver metastases

Opinion Statement Liver metastases, especially from colorectal primary cancers, are treatable and potentially curable. Imaging techniques such as CT, MRI, and sonography have advanced in recent years and led to increased sensitivity and specificity in the diagnosis of liver metastases. Liver surgery also has been revolutionized in the past two decades. Dissections along nonanatomic lines have permitted the resection of multiple lesions that previously might have been considered unresectable. We regard resection of a solitary hepatic metastasis or up to four metastases from colorectal carcinoma as the best treatment for this condition. In patients over 70 years of age and those with medical conditions preventing surgery, we endorse expectant follow-up as long as the tumor remains stable. But if the tumor begins growing rapidly and local techniques cannot be used, we consider systemic chemotherapy. In patients with progressive metastatic liver disease, we initiate systemic therapy or hepatic arterial infusion. In young patients with metastatic disease, even when the disease is indolent or symptomatic, it may be difficult not to treat. We use either local regional therapy (resection or regional infusion) or systemic chemotherapy followed by regional therapy. In patients with neuroendocrine tumors metastatic to the liver, the first approach we use is not to treat because there may be a long period of stable disease. We use Sandostatin (Sandoz Pharmaceuticals, East Hanover, NJ) to treat symptoms. If the tumor progresses and symptoms cannot be controlled, these vascular tumors can be treated by embolization or chemoembolization, with high expectations of response. Newer approaches to liver metastases such as cryosurgery, chemoembolization, and interstitial radiation are also available. Cryosurgery is an ablative procedure that has not been proven yet to be as effective as surgical removal of metastases. However, in a situation where surgery cannot be performed, cryosurgery is an alternative. Chemoembolism has not been proven to be more effective than systemic therapy for liver metastases, but it allows another regional approach. External localized radiation can be used for patients who fail first-line treatment or in new protocols to delineate its value, perhaps in concert with chemotherapy. We also consider offering external localized radiation in patients who fail first-line treatment, perhaps in concert with chemotherapy. The usefulness of these techniques compared with surgery or regional therapy is being investigated.     

Recent advances in the treatment of colorectal liver metastases

Liver metastases are the major cause of death coloroctal resection for cancer. Colorectal liver metastases are unique because of the potential for cure. Presently surgical resection is the gold standard of treatment. Complete R0 resection gives 5-year survival of up to 24-44%. Over the years there have been extensive efforts in devising new modalities of treatment for this disease. These include methods to increase the resectability such as portal after vein emolization & two-stage surgery, py with newer drugs and methods such chronotherapy & hepatic artery infusion chemotherapy, newer methods of radiotherapy, local ablative therapies such as cryoablation, radiofequency ablation, microwave ablation & laser interstitial thermal therapy, and biological therapy. Biological therapy is largely investigational, but holds great promise for the future.     

原发性肝癌多学科整体治疗方案的设计与实施

恶性肿瘤的治疗模式正在经历从传统的单项专科治疗向联合治疗,再向多学科综合治疗的转变。笔者提出了以整体医学观为基础的肿瘤多学科整体治疗(MDHT)模式以指导肿瘤综合治疗方案的设计与实施。MDHT模式涉及治疗目标、治疗方法和治疗疗程三个方面。以原发性肝癌为例,可以将整体治疗的靶向目标分为肿瘤局部病灶、区域病灶、系统病灶、器官基础病、全身内环境以及康复等六项基本目标。针对MDHT模式中各项治疗目标,可分别采用多种治疗方法的序贯疗法、同步治疗和交替疗法。整体治疗方案的实施是由不同治疗方法的多个治疗疗程来实现的。在肿瘤MDHT模式中,多学科治疗是治疗方式的体现,整体治疗是治疗目标的追求。MDHT的理念有助于指导多学科团队设计和实施肿瘤综合治疗方案。     

Selection criteria for liver resection in patients with hepatocellular carcinoma and chronic liver disease

Hepatocellular carcinoma （HCC） is one of the most common malignancies worldwide with an annual occurrence of one million new cases. An etiologic association between HBV infection and the development of HCC has been established with a relative risk 200-fold greater than in non-infected individuals. Hepatitis C virus is also proving an important predisposing factor for this malignancy with an incidence rate of 7% at 5 years and 14% at 10 years. The prognosis depends on tumor stage and degree of liver function, which affect the tolerance to invasive treatments. Although surgical resection is generally accepted as the treatment of choice for HCC, new treatment strategies, such as local ablative therapies, transarterial embolization and liver transplantation, have been developed nowadays. With increasing detection of small HCCs from screening programs for cirrhotic patients, it is foreseen that locoregional therapy will play an important role in the near future.     

慢性肝炎肝纤维化中西医结合治疗问题

慢性肝炎肝纤维化主要由乙、丙型肝炎所致,合理治疗应包括抗病毒、调节免疫及抗肝纤维化治疗,有效抗病毒是治疗本病的关键,以西药为主辅以中药可提高疗效。当前在所谓的保（护）肝及对肝纤维化治疗方面药物虽多,但迄今尚乏特（有）效药物。研究表明：以＂瘀血证＂立论,重用丹参配黄芪活血化瘀为主,益气、舒肝、健脾中医中药对肝细胞炎症、坏死及肝纤维化等病变治疗具有良好作用。但面对众多慢性肝炎、肝纤维化患者,可用于临床的抗肝纤维化有效治疗措施仍很有限,而且目前＂861＂、＂益肝康颗粒剂＂;强肝、扶正化瘀胶囊等有效中药投产者不多,尚需做进一步随机对照、盲法、大样本、多中心临床试验研究,并重视肝组织学治疗前后复查结果,进一步验证疗效。     

Endoscopic therapy for Barrett's esophagus and early esophageal cancer:Where do we go from here?

Since Barrett's esophagus is a precancerous condition,efforts have been made for its eradication by various ablative techniques.Initially,laser ablation was attempted in non-dysplastic Barrett's esophagus and subsequently,endoscopic ablation using photodynamic therapy was used in Barrett's patients with high-grade dysplasia who were poor surgical candidates.Since then,various ablative therapies have been developed with radiofrequency ablation having the best quality of evidence.Resection of dysplastic areas only without complete removal of entire Barrett's segment is associated with high risk of developing metachronous neoplasia.Hence,the current standard of management for Barrett's esophagus includes endoscopic mucosal resection of visible abnormalities followed by ablation to eradicate remaining Barrett's epithelium.Although endoscopic therapy cannot address regional lymph node metastases,such nodal involvement is present in only 1% to 2% of patients with intramucosal adenocarcinoma in Barrett esophagus and therefore is useful in intramucosal cancers.Post ablation surveillance is recommended as recurrence of intestinal metaplasia and dysplasia have been reported.This review includes a discussion of the technique,efficacy and complication rate of currently available ablation techniques such as radiofrequency ablation,cryotherapy,argon plasma coagulation and photodynamic therapy as well as endoscopic mucosal resection.A brief discussion of the emerging technique,endoscopic submucosal dissection is also included.     

肝细胞癌诊治中的若干问题

随着肝细胞癌（HCC）肿瘤标志物和CT／MRI诊断的应用、手术切除及局部消融等治疗方法的进步,使HCC的5年生存率达到了63．4％。但是由于我国HCC早期诊断水平的不均衡,可进行手术切除的病例仅仅有20％～30％。对于高危人群定期开展血清肿瘤标志物和肝脏超声检查;提高三期动态增强CT和Gd—DTPA增强MRI等影像学诊断水平,同时积极开展多学科会诊,制定个性化治疗方案和减少术后肝功能衰竭发生等若干问题,是提高我国HCC早期诊断水平,提高治疗效果,延长生存期的有效手段。     

中药治疗非酒精性脂肪性肝纤维化的研究现状

非酒精性脂肪性肝纤维化是非酒精性脂肪性肝炎（NASH）进展为终末期肝病的关键病理阶段,其有效治疗亟待解决。中药具有多组分及多途径、多靶点作用的特点,对非酒精性脂肪性肝纤维化具有综合治疗的优势,可通过调节肝脏脂质代谢、抑制氧化应激反应及肝细胞凋亡、调节炎症、纤维化相关基因的表达等阻止肝脂肪变、炎症及纤维化的发生与进展。