消化系肿瘤最新治疗

近年有不少新疗法用于治疗肝癌、胰癌和消化道癌肿。主要有以下几种： 一、“氩氦刀”冷冻治疗 冷冻或超低温疗法（Ｃｒｙｏｔｈｅｒｅｐｙ）在临床上已用多年，但主要用于浅表或易于直接接触部位的肿瘤，且多用于治疗无法切除的或转移性癌肿。主要困难在于无合适的冷冻机和冷冻头，不能使肿瘤内温度快速降至希冀的水平。“氩氦刀”为临床提供了理想的冷冻手段，不仅可在手术直视下准确冷冻肿瘤组织，而且可在超声／ＣＴ引导下经皮穿刺治疗。 “氩氦刀”系美国Ｅｎｄｏｃａｒｅ公司采用太空火箭制导技术，研制成功的氩氦刀超导手术系统。该…     

经皮穿刺氩氦刀靶向冷冻治疗非小细胞肺癌疗效观察

目的 观察经皮穿刺氩氦刀靶向冷冻治疗非小细胞肺癌（NSCLC）的效果.方法 由CT或C臂引导,对786例NSCLC患者行经皮穿刺氩氦刀靶向冷冻治疗,术后行化疗272例、放疗163例.结果 本组术后2～4周冷冻瘤体组织病理切片显示,68.72％（156/227）可见典型的凝固性坏死,34.36％（78/227）呈现无组织坏死,均未见肿瘤组织结构;术后1、3、5年生存率分别为72.65％、27.11％、9.96％,中位生存期14.6个月.结论 经皮穿刺氩氦刀靶向冷冻治疗NSCLC效果较好.     

肝癌冷冻治疗的临床研究进展

对于不能手术切除的肝癌,无论是原发或是继发,冷冻治疗都是一种重要选择。冷冻治疗具有坏死彻底、适应性广、创伤小、可控性强等优点;冷冻消融后的瘤苗作用还能提高患者的抗肿瘤免疫力,冷冻导致的血管栓塞能阻止肿瘤通过血行转移;冷冻治疗不仅能用于治疗小肝癌,对大肝癌和邻近大血管的肝癌均适用。冷冻疗法可在手术中应用,也町经腹腔镜或经皮穿刺完成治疗过程;在超声或CT引导下,经皮氩氦刀冷冻消融对于小肝癌的治疗效果等同于外科手术.     

氩氦刀冷冻消融术治疗原发性肝癌发热原因分析

目的探讨氩氦刀冷冻消融术治疗原发性肝癌后患者出现的发热、并发感染及易感因素。方法回顾性分析338例接受氩氦刀冷冻消融术治疗的原发性肝癌患者的临床资料,分析术后发热和并发感染情况及易感因素。结果术后出现发热196例(57.99%),并发感染4例(1.18%)。出现发热与患者肿瘤大小、肿瘤毀损面积、肝功能、巴塞罗那临床肝癌分期及糖尿病等密切相关,并发感染与肿瘤毀损面积、术前白细胞水平及发热时间密切相关。结论发热是氩氦刀冷冻消融术治疗原发性肝癌的术后常见症状,肿瘤大、毁损面积大、Child-Pugh分级和术前白细胞水平低为发生发热的易感因素。患者术后并发感染率低,肿瘤毀损面积大、术前白细胞水平低及发热时间长等为发生感染的易感因素。     

肺癌冻融治疗对临近大血管及心脏的影响

目的观察肺癌氩氦冻融治疗过程中对临近大血管及心脏的影响。方法96例侵犯心脏及大血管的肺癌患者,在CT引导下经皮肺穿刺行氩氦刀治疗,术后用CT监测冰球大小和肿瘤的消融范围。冻融前先行血管增强扫描或PET-CT检查,明确肿瘤与临近器官的关系,但应避免误穿。结果所有患者均在局麻下完成了经皮肺穿刺行氩氦刀治疗。在上腔静脉、主动脉等大血管附近的肺癌,经氩氦刀冷冻形成的冰球不对称,临近心血管部位的冰球较小,融化较快,但冻融过程中无严重不良反应发生。结论氩氦刀对大血管及心脏无明显影响,对包绕于大血管和侵犯心脏的肿瘤可直接冷冻。     

CT引导下经皮肺穿刺氩氦冷冻消融术治疗肺癌（附152例报告）

目的观察CT引导下经皮肺穿刺氩氦冷冻消融术治疗肺癌的疗效。方法 152例肺癌患者,均采用CT引导下经皮肺穿刺氩氦冷冻消融术治疗,共冷冻病灶186个。结果本组患者冰球覆盖肿瘤面积77.3%±0.7%,显效率75.8%。其中肿瘤直径≤4 cm者冰球覆盖肿瘤面积95.1%±0.8%、显效率93.9%,直径〉4 cm者分别为59.5%±0.9%、55.2%,二者冰球覆盖肿瘤面积和显效率相比P均〈0.05。中央型肺癌肿瘤直径（5.9±0.6）cm、冰球覆盖肿瘤面积60.1%±0.5%、显效率60.0%,周围型肺癌分别为（3.0±0.3）cm、97.1%±0.9%、94.1%,二者病灶直径、冰球覆盖肿瘤面积和显效率相比P均〈0.05。手术过程顺利,无1例术中死亡,术后并发症较少且可控制。术后1月瘤体变小有效率69.8%,51例有空洞形成;术后12个月有效率仍达44.0%,罕有空洞,但CR百分比较术后1个月时增加,残留肿瘤的瘤体也渐增大。结论经皮肺穿刺氩氦冷冻消融术治疗肺癌,手术过程简单,安全性好,术后并发症较少且能有效地减轻患者肿瘤负荷,提高生存质量。     

经皮氩氦刀冷冻消融治疗老年肝癌20例

磁共振导引下氩氦刀靶向冷冻消融术是近年开展的冷冻治疗新技术,利用局部超低温冷冻的方法损毁肿瘤组织,避免了因开刀手术导致过量肝组织被切除使肝脏功能受到影响,因而使一些无法耐受肝脏手术的老年肿瘤病人可以接受该治疗[1].本文通过对经皮穿刺氩氦刀冷冻消融治疗老年肝癌进行临床总结,探讨此疗法治疗肝癌的适应证、疗效及安全性和临床意义.     

氩氦刀治疗肝细胞癌早期疗效的MRI评价

目的探讨氩氦刀冷冻消融术治疗肝细胞癌(hepatocellular carcinoma,HCC)早期疗效的MRI特征。方法应用氩氦刀治疗53例HCC患者的59个病灶,并回顾性分析治疗前后的MRI图像,评价早期疗效,探讨肿瘤完全坏死和残留的MRI特点。结果治疗后59个病灶中41个(69.5%)完全坏死,18个(30.5%)肿瘤残留。术后3～7d(A组)、4～6周(B组)及12～15周(C组)复查MRI评估疗效,疗效评估诊断(完全坏死/肿瘤残留)分别为36/23、39/20、40/19,3组疗效评估结果一致。氩氦刀治疗后早期(A组)T1加权像(T1weightedimage,T1WI)消融区低信号、瘤结节高信号及瘤周0.5cm消融边界为肿瘤坏死完全的可靠征象,T2加权像(T1weightedimage,T2WI)消融区呈环形且厚度均匀的高信号为炎性反应。T2WI消融区局灶性高信号及增强扫描不规则强化仍是诊断肿瘤残留的"金标准"。结论 MRI评价氩氦刀治疗HCC的早期疗效具有及时、准确、特异性高、无辐射的优点,术后3～7d即可进行早期评价。T1WI具有较高的诊断价值,T2WI信号及增强扫描仍是评价疗效的关键。     

CT灌注成像引导下氩氦刀微创冷冻消融术对肝癌的治疗效果分析

目的分析CT灌注成像(CTPI)引导下氩氦刀微创冷冻消融术对肝癌的治疗效果。方法选取2015年9月—2017年8月在河北工程大学附属医院行CTPI引导下氩氦刀微创冷冻消融术的肝癌患者30例,回顾性分析其术后1个月治疗效果、术后1周内并发症发生情况、术后12个月复发情况,并观察术前甲胎蛋白(AFP)异常患者术后1个月恢复正常情况。结果 (1)30例患者术后1个月完全缓解(CR)16例,部分缓解(PR)8例,疾病稳定(SD)3例,疾病进展(PD)3例,有效率为90.0%(27/30)。(2)30例患者术后1周内出现疼痛24例,低热9例,呕吐4例,无一例出现冻伤、皮下出血、肝周脓肿。(3)30例患者术后12个月复发13例,复发率为43.3%。(4)25例术前AFP异常患者术后1个月恢复正常15例,AFP恢复正常者所占比例为60.0%。结论 CTPI引导下氩氦刀微创冷冻消融术可有效提高肝癌患者治疗效果、手术精准度,有利于减少并发症的发生及复发。     

综合靶向消融治疗中晚期肝癌的临床研究

目的 探讨用氩氦刀冷冻 微波消融 化学消融等综合靶向消融治疗中晚期肝癌的疗效.方法 78例中晚期肝癌患者采用综合靶向消融治疗,先行肝动脉栓塞化疗,一周后行局部氩氦刀冷冻术、微波消融或化学消融术;56例单纯行动脉栓塞化疗.结果 治疗组1年生存率56.4%,对照组1年生存率36.9%;治疗组AFP平均值低于对照组,有显著性差异.结论 综合靶向消融治疗能提高中晚期肝癌患者的生存率,较单纯介入疗法治疗更为有效.     

Analysis of clinical effect of high-intensity focused ultrasound on liver cancer

AIM: To evaluate the clinical effect of high-intensity focused ultrasound (HIFU) in the treatment of patients with liver cancer. METHODS: HIFU treatment was performed in 100 patients with liver cancer under general anesthesia and by a targeted ultrasound. Evaluation of efficacy was made on the basis of clinical symptoms, liver function tests, AFP, MRI or CT before and after the treatment. RESULTS: After HIFU treatment, clinical symptoms were relieved in 86.6%(71/82) of patients. The ascites disappeared in 6 patients. ALT (95+/-44) U/L and AST (114+/-58) U/L before HIFU treatment were reduced to normal in 83.3%(30/36) and 72.9%(35/48) patients, respectively, after the treatment. AFP was lowered by more than 50% in 65.3%(32/49) patients. After HIFU treatment, MRI or CT findings indicated coagulation necrosis and blood supply reduction or disappearance of tumor in the target region. CONCLUSION: HIFU can efficiently treat the patients with liver cancer. It will offer a significant noninvasive therapy for local treatment of liver tumor.     

Analysis of clinical effect of high-intensity focused ultrasound on liver cancer

AIM:To evaluate the clinical effect of high-intensity focusedultrasound(HIFU)in the treatment of patients with livercancer.METHODS:HIFU treatment was performed in 100 patientswith liver cancer under general anesthesia and by atargeted ultrasound.Evaluation of efficacy was made onthe basis of clinical symptoms,liver function tests,AFP,MRI or CT before and after the treatment.RESULTS:After HIFU treatment,clinical symptoms wererelieved in 86.6%(71/82)of patients.The ascitesdisappeared in 6 patients.ALT(95±44)U/L and AST(114±58)U/L before HIFU treatment were reduced tonormal in 83.3%(30/36)and 72.9%(35/48)patients,respectively,after the treatment.AFP was lowered by morethan 50% in 65.3%(32/49)patients.After HIFU treatment,MRI or CT findings indicated coagulation necrosis and bloodsupply reduction or disappearance of tumor in the target region.CONCLUSION:HIFU can efficiently treat the patients withliver cancer.It will offer a significant noninvasive therapyfor local treatment of liver tumor.     

Cryosurgery with combination of (125)iodine seed implantation for the treatment of locally advanced pancreatic cancer

OBJECTIVE: To study the therapeutic value of cryosurgery with combination of (125)iodine seed implantation for locally advanced pancreatic cancer. METHODS: Thirty-eight patients with locally advanced pancreatic cancer were enrolled in this study. The diagnosis was confirmed by pathology in 31 patients. Ten patients had metastases of the peripancreatic lymph node and eight had liver metastases. The therapy included cryosurgery, which was performed intra-operatively or percutaneously under guidance of ultrasound and/or computed tomography (CT), and (125)iodine seed implantation, which was performed during cryosurgery process or post-cryosurgery under the guidance of ultrasound and/or CT. RESULTS: Eleven patients received intra-operative cryosurgery and 27 received percutaneous cryosurgery. Fourteen patients underwent two procedures of cryosurgery and three underwent three procedures of cryosurgery. (125)Iodine seed implantation was performed during the freezing procedure in 29 patients and within 3-7 days after cryosurgery in nine patients under ultrasound and CT guidance. Fifteen patients, of whom 13 had metastases of peripancreatic lymph nodes or liver received regional chemotherapy. At 3 months after therapy, a CT follow-up was performed to estimate the tumor response to therapy. Most of the patients had varying degrees of tumor necrosis. A complete response of the tumor was seen in 23.6% of patients, a partial response in 42.1%, stable disease in 26.3% and progressive disease in 7.9%. The adverse effects associated with cryosurgery mainly included pain of the upper abdomen and increased serum amylase activity. Acute pancreatitis was seen in five patients, one of whom presented a severe type of pancreatitis. During the followed-up of a median of 16 months (range of 5-37) median overall survival was 12 months, 19 patients (50.0%) survived for 12 months or longer and four survived for 24 months or longer. CONCLUSION: As it is far less invasive than conventional pancreas resection and entails a low rate of adverse effects, cryosurgery should be the choice modality for most patients with locally advanced pancreatic cancer. (125)Iodine seed implantation can destroy residue survival cancer cells after cryosurgery. Hence, combination of both modalities has a complementary effect.     

经皮射频消融治疗肝脏肿瘤近期疗效观察

目的：探讨经皮射频消融(PRFA)对肝脏恶性肿瘤的治疗效果。方法：利用RF—2000^TM肿瘤射频治疗系统，在B超或CT引导下对55例肝恶性肿瘤患者73个肿块进行经皮肝穿刺射频热凝治疗，并用B超及CT检查以了解PRFA治疗效果。结果：PRFA治疗后60．9％(42／9)的肿块血供消失，61．6％(45／73)的肿块呈完全凝固性坏死。其中直径小于3cm中的20个肿块(另4个治疗前即无血供)全部血供消失(100％)，24个肿块呈完全凝固性坏死(100％)；直径为3-5cm的18个肿块中16个血供消失(88．9％)，14个完全凝固性坏死(77．8％)；而直径大于5cm的肿瘤则治疗后肿块血供完全消失及完全凝固性坏死率均显著降低。肿瘤直径小于5cm的患者生存期较长。结论：集束电极PRFA治疗肝脏恶性肿瘤创伤小，安全，疗效可靠。肿瘤越小治疗效果越好。     

Therapeutic effectiveness of echo-guided percutaneous radiofrequency ablation therapy with a LeVeen needle electrode in hepatocellular carcinoma

AIM:To investigate the results of radiofrequencyablation(RFA)in obtaining the necrosis of hepatocellularcarcinoma(HCC)in cirrhotic patients and to assessthe results of RFA in relation to recurrence of HCC andsurvival of the treated patients.METHODS:Fifty-six consecutive cirrhotic patients with63 HCCs were treated with RFA between May 2000 andMay 2004.The diameter of the HCCs ranged from 1 cmto 5 cm(mean 2.8 cm).In all cases RFA was performedwith percutaneous approach under ultrasound guidanceusing expandable needle electrode(LeVeen needle).Treatment efficacy and recurrence were evaluated withdual-phase spiral computed tomography(CT).RESULTS:Complete necrosis after single or multipletreatment was achieved in 96.8%(61/63)tumors.We observed recurrence after complete necrosis in 23patients(41%)during a mean follow-up of 32.3 months.The recurrences were local in 2 patients(8.6%)and indifferent segments in 21(91.4%).Major complicationsoccurred in 3 patients(4%).During follow-up period,32(57.1%)patients died;15 due to progression of HCC,11 from liver failure,3 from esophageal varices bleedingand 3 from the causes not related to liver disease.CONCLUSION:RFA with LeVeen needle is an effectiveand safe treatment for HCC<5 cm in cirrhotic patients.It has yet to be established how far this treatmentinfluences the survival rate of patients.It becomesimportant to establish treatments to prevent recurrencesin different segments,such as interferon therapy.     

进展期肝癌患者氩氦刀冷冻消融术前中性粒细胞/淋巴细胞比值与术后预后关系研究

目的探讨氩氦刀术前中性粒细胞/淋巴细胞比值(neutrophil/lymphocyte ratio,NLR)与进展期肝癌患者术后生存期的关系。方法回顾性分析2008—2009年在我院行氩氦刀冷冻消融治疗的150例进展期肝癌患者临床资料,根据术前NLR中位数(2.94)将患者分为2组(高NLR组和低NLR组),对2组进行生存分析和Cox回归分析。结果氩氦刀冷冻消融术前病理组织分化程度、NLR和肝硬化Child-Pugh分级是术后进展期肝癌患者生存期的影响因素。术前高NLR组患者生存期为5个月(95%CI 3.5~6.4),而低NLR组患者生存期为9个月(95%CI 6.9~11.0),2组生存期差异有统计学意义。结论 NLR2.94的进展期肝癌患者行氩氦刀冷冻消融治疗预后较差。     

Ultrasonically controlled percutaneous high frequency thermotherapy of liver tumors with perfused needle electrodes

Percutaneous radiofrequency ablation (HFTT) is a new therapeutic technique for the treatment of inoperable primary and secondary liver tumors. We report our initial experience using a newly developed perfusion electrode. Twelve liver tumors (11 metastases of colorectal tumors, 1 hepatocellular carcinoma) were treated in 5 inoperable patients. The patients had 1 to 3 liver tumors. All lesions were cytologically confirmed and measured 12-47 mm. The technique was approved by the institutional review board and informed consent was obtained from all patients. A 12-mm-needle electrode with a 15-mm-active tip was introduced into the liver tumors under ultrasound guidance and tumors were coagulated with radiofrequency energy of 350 kHz. The needle electrodes were perfused with 0.9% saline during coagulation to increase the volume of coagulation necrosis without tissue vaporization. The serial changes in tumor size after therapy were evaluated with spiral CT imaging. Dynamic CT showed that unenhanced areas indicative of coagulation necrosis developed in all tumors. In 8 of 12 tumors no signs of recurrence appeared during the observation period of 7 (5-12) months. No major complications were observed. Our preliminary experience suggests that percutaneous radiofrequency coagulation can be a simple, safe and potentially effective treatment for selected patients with inoperable liver tumors. The results justify further studies to investigate the possible role in clinical practice.     

Rapid progression of hepatocellular carcinoma after Radiofrequency Ablation

AIM: To report the results of radiofrequency ablation (RFA) of hepatocellular carcinoma (HCC) in cirrhotic patients and to describe the treatment related complications (mainly the rapid intrahepatic neoplastic progression). METHODS: Eighty-seven consecutive cirrhotic patients with 104 HCC (mean diameter 3.9 cm, 1.3 SD) were submitted to RFA between January 1998 and June 2003. In all cases RFA was performed with percutaneous approach under ultrasound guidance using expandable electrode needles. Treatment efficacy (necrosis and recurrence) was estimated with dual phase computed tomography (CT) and alpha-fetoprotein (AFP) level. RESULTS: Complete necrosis rate after single or multiple treatment was 100%, 87.7% and 57.1% in HCC smaller than 3 cm, between 3 and 5 cm and larger than 5 cm respectively (P=0.02). Seventeen lesions of 88(19.3%) developed local recurrence after complete necrosis during a mean follow up of 19.2 mo. There were no treatment-related deaths in 130 procedures and major complications occurred in 8 patients (6.1 %). In 4 patients, although complete local necrosis was achieved, we observed rapid intrahepatic neoplastic progression after treatment. Risk factors for rapid neoplastic progression were high preoperative AFP values and location of the tumor near segmental portal branches. CONCLUSION: RFA is an effective treatment for hepatocellular carcinoma smaller than 5 cm with complete necrosis in more than 80% of lesions. Patients with elevated AFP levels and tumors located near the main portal branch are at risk for rapid neoplastic progression after RFA. Further studies are necessary to evaluate the incidence and pathogenesis of this underestimated complication.     

Percutaneous microwave coagulation therapy for unresectable hepatocellular carcinoma

BACKGROUND/AIMS: Percutaneous microwave coagulation therapy (PMCT) has recently been introduced as a new treatment for hepatocellular carcinoma (HCC) in Japan. This study was performed to evaluate its efficacy and safety. METHODOLOGY: Thirteen patients with 17 nodules of unresectable HCC were subjected to PMCT under ultrasonic guidance. The tumors ranged from 1.2-4.4 cm in size. Assessment of the efficacy of PMCT was made by follow-up with dynamic computed tomography (CT). RESULTS: In the patients with small HCC (< or = 2.0 cm), 8 of 10 nodules (80%) showed complete remission after PMCT. In small nodules located on the liver surface, 3 out of 4 nodules (75%) showed complete remission. However, in the patients with larger HCC (> or = 2.1 cm), 5 out of 7 nodules developed local recurrence after PMCT. Regarding assessment of the necrotic area after PMCT, dynamic CT revealed enhancement that was possibly caused by congestion of the liver parenchyma surrounding the area of necrosis due to PMCT in the early phase of the treatment. Therefore, the necrotic area must be assessed carefully. Although a slight heat sensation and/or pain during microwave irradiation (a common effect of PMCT) occurred in all patients, there were no serious adverse effects. CONCLUSIONS: Complete remission of small HCC (< or = 2 cm in diameter) can be achieved with PMCT alone, but there seem to be limitations to its effectiveness with larger HCC (> or = 2.1 cm). There were no serious adverse effects from PMCT and the therapy can be safely carried out even in patients with poor liver function.     

Outcomes of ultrasound-guided percutaneous argon-helium cryoablation of hepatocellular carcinoma

Purpose

To evaluate the efficacy and safety of ultrasound (US)-guided percutaneous argon-helium cryoablation for hepatocellular carcinoma (HCC) and determine appropriate indications.

Methods

We reviewed outcomes of 300 HCC patients who underwent US-guided percutaneous cryoablation.

Results

Overall, 223 tumors (mean diameter 7.2?±?2.8?cm) in 165 patients were incompletely ablated, while 185 tumors (mean diameter 5.6?±?0.8?cm, P?=?0.0001 vs. incomplete ablation) in 135 patients were completely ablated. Nineteen patients (6.3%) developed serious complications while in hospital, including cryoshock syndrome in six patients, hepatic bleeding in five, stress-induced gastric bleeding in four, liver abscess in one and intestinal fistulas in one. Two patients died because of liver failure. The median follow-up was 36.7?months (range 6–63?months). The local tumor recurrence rate was 31%, and was related to tumor size (P?=?0.029) and tumor location (P?=?0.037). The mean survival duration of patients with early, intermediate and advanced HCC (Barcelona Clinic Liver Cancer staging system) was 45.7?±?3.8, 28.4?±?1.2 and 17.7?±?0.6?months, respectively.

Conclusions

US-guided percutaneous cryoablation is a relatively safe and effective therapy for selected HCC patients.