肝癌合并门静脉癌栓的外科治疗

肝癌合并门静脉癌栓 (ｔｕｍｏｒｔｈｒｏｍｂｕｓｉｎｔｈｅｐｏｒ ｔａｌｖｅｉｎ ,ＴＴＰＶ)是肝癌发生、发展过程中出现的一种病理现象。根据尸检、影像学及肝癌病理学检查2 0 %～ 70 %的原发性肝癌伴有ＴＴＰＶ[1] 。ＴＴＰＶ是肝癌预后差的一个主要因素。肝癌周边血供主要来自门静脉 ,而门静脉管壁又较薄 ,最易被组织侵犯。癌栓可由患侧分支蔓延至主干 ,或延至对侧分支 ,引起肝内转移、门脉高压、食道胃底静脉曲张破裂出血或顽固性腹水。癌栓还可经肝短静脉和肝静脉进入下腔静脉 ,可引起肺梗塞或右心房癌栓梗塞 ,导致更严重的症状。过…     

肝癌合并门静脉癌栓的外科处理

目的：研究肝细胞肝癌合并门静脉癌栓患者外科治疗的效果及影响因素。方法：对３１例肝癌合并门静脉主干及其大分支癌栓患者在电凝锐性解剖肝门的基础上,采用肝叶切除加癌栓清除、门静脉主干切开取栓等术式治疗,并对癌栓的临床病理学类型进行探讨。结果：与非治疗者相比,外科治疗明显延长了患者的术后生存期,疗效最好的方法是肝叶切除加取栓术,１８例术后平均存活时间１５个月,门静脉主干切开取栓术次之,８例平均存活８个月。所有取栓成功的患者术后均无食管静脉曲张破裂出血。癌栓的病理类型以增殖型最多见,机化型罕见,但由于癌栓与门静脉壁紧密粘连,不易清除,后者不宜外科治疗。结论：外科治疗有效地防止了肝癌合并门静脉癌栓的严重并发症──急性上消化道出血,并延长、改善了患者的生存期和生命质量。     

合并门静脉癌栓的肝细胞癌外科治疗策略

<正>肝细胞肝癌位列全世界肿瘤发病率第5位,在我国,其发病率及病死率均居恶性肿瘤的第2位,此外,肝癌术后5年的累计复发率为77%～100%[1]。门静脉癌栓(portal vein tumor thrombus,PVTT)形成是肝癌的生物学特征之一,也是肝癌术后复发和肝内播散的主要原因。临床报道肝癌合并PVTT发生率为44.0%～62.2%[2],无干预情况下中位生存期仅为2.7个月[3]。对于该类患者的处理,以往     

肝癌合并门静脉癌栓的诊断和治疗

肝癌合并门静脉癌栓的诊断和治疗上海医科大学中山医院肝癌研究所（２０００３２）周信达余耀近年来，原发性肝癌的早期发现和肝切除术的进展改善了肝癌的预后和总体疗效，但肝切除术在某些方面仍受到很大限制，如肿瘤巨大、肿瘤多发、局部浸润或转移、合并严重肝硬化等。...     

原发性肝癌合并门静脉癌栓不同治疗方法的疗效分析

目的 比较原发性肝癌(HCC)合并门静脉癌栓(PVTT)不同治疗方法的疗效,探讨影响患者术后的预后因素.方法 回顾性分析我院2005年1月至2012年12月收治的539例HCC合并PVTT患者的临床资料.根据治疗方案的不同,将患者分为四组:保守治疗组(A组,47例)、单纯化疗组(B组,84例)、单纯手术组(C组,119例)、综合治疗组(D组,289例).结果 四组基线临床资料,包括肿瘤的数目、大小、门静脉癌栓分布等无明显差异(P＞0.05).手术治疗及化疗均可提高患者的生存率,综合治疗有明显的优势.单因素、多因素分析提示肿瘤大小、肿瘤数目、门静脉癌栓分布及术后化疗次数是影响手术切除后疗效的危险因素.结论 对于HCC合并PVTT患者,积极手术治疗是有效的方法,术后联合化疗可提高患者的生存率.如患者病情可耐受,可行多次化疗栓塞.     

原发性肝癌合并门静脉癌栓的治疗进展

目的综述肝癌合并门静脉癌栓(PVTT)的治疗现状,以进一步提高其疗效。方法通过文献检索对近年来与肝癌合并PVTT有关的治疗方法和治疗效果进行总结。结果 PVTT是肝癌的常见合并症,其治疗方法有外科手术切除、肝动脉栓塞和化疗、经门静脉治疗、放射性治疗、各种消融治疗、分子靶向治疗等;肝癌合并PVTT患者的手术切除率低,治疗困难且预后差,疗效有待提高。结论肝癌合并PVTT的治疗应以手术为主,多学科、多手段联合治疗,并根据患者的病情及癌栓的情况进行个体化和序贯性的综合治疗,以提高肝癌合并PVTT患者的生存率。     

肝癌门静脉癌栓的外科治疗

肝细胞肝癌(简称肝癌)列全世界肿瘤发病率第5位，每年全世界的发病人数约564000，而死亡人数大致与其相似，在这些患者中，有一半以上在中国。虽然肝癌的早期诊断、外科技术和围手术期处理的进步以及肝移植等新技术的发展，肝癌的术后生存率明显提高，但从整个肝癌患者人群来说，总的5年生存率仍不足5％，其主要原因之一是门静脉癌栓(portal vein tumor thrombus，PVTT)的形成．根据尸检和影像学检查，门静脉癌栓的发生率约20％～70％。肝癌具有侵犯血管的特性，最多见门静脉，门静脉癌栓形成一方面引起肿瘤细胞的肝内播散和转移，另一方面可以加重肝硬变患者门脉高压而引起上消化道大出血，甚至导致肝功     

取栓术和栓塞化疗在提高合并门静脉癌栓肝癌手术疗效中？…

目的 探讨肝癌合并门静脉癌栓的手术疗效,评价术中门静脉癌栓取出术和术后辅助肝动脉栓塞化疗对提高肝癌术后生存率的影响。方法 对１０６例肝癌合并门静脉癌栓接受不规则性肝叶切除术的病人进行临床分组研究,分别采用单纯手术切除;手术切除加术中取栓术、术中取栓术后辅助肝动脉栓塞化疗,比较各组的疗效。结果 全组病人的１,３和５年生存率分别为３６．１％,２４．７％和２４．７％。单纯手术切除组（１例）的１、３、和５     

肝癌合并门静脉癌栓行超选择性肝动脉栓塞化疗病人的护理

肝动脉栓塞化疗(TAE)是目前非手术治疗原发性肝癌有效的首选治疗方法。但合并门静脉癌栓时,化疗后易出现肝功能衰竭,曾被认为是栓塞化疗的禁忌证。我科     

Surgical Outcomes in Hepatocellular Carcinoma Patients with Portal Vein Tumor Thrombosis

Background

Different approaches to surgical treatment of portal vein tumor thrombosis (PVTT) have been advocated. This study investigated the outcomes of different surgical approaches in hepatocellular carcinoma (HCC) patients with PVTT.

Methods

We reviewed prospectively collected data for all patients who underwent hepatectomy for HCC at our hospital between December 1989 and December 2010. Patients were excluded from analysis if they had extrahepatic disease, PVTT reaching the level of the superior mesenteric vein, or hepatectomy with a positive resection margin. The remaining patients were divided into three groups for comparison: group 1, with ipsilateral PVTT resected in a hepatectomy; group 2, with PVTT extending to or beyond the portal vein bifurcation, treated by en bloc resection followed by portal vein reconstruction; group 3, with PVTT extending to or beyond the portal vein bifurcation, treated by thrombectomy.

Results

A total of 88 patients, with a median age of 54 years, were included in the analysis. Group 2 patients were younger, with a median age of 43.5 years versus 57 in group 1 and 49 in group 3 (p = 0.017). Group 1 patients had higher preoperative serum alpha-fetoprotein levels, with a median of 8,493 ng/mL versus 63.25 in group 2 and 355 in group 3 (p = 0.004), and shorter operation time, with a median of 467.5 min versus 663.5 in group 2 and 753 in group 3 (p = 0.018). No patient had thrombus in the main portal vein. Two (2.8 %) hospital deaths occurred in group 1 and one (10 %) in group 2, but none in group 3 (p = 0.440). The rates of complication in groups 1, 2, and 3 were 31.9, 50.0, and 71.4 %, respectively (p = 0.079). The median overall survival durations were 10.91, 9.4, and 8.58 months, respectively (p = 0.962), and the median disease-free survival durations were 4.21, 3.78, and 1.51 months, respectively (p = 0.363). The groups also had similar patterns of disease recurrence (intrahepatic: 33.8 vs. 28.6 vs. 40.0 %; extrahepatic: 16.9 vs. 14.3 vs. 0 %; both: 28.2 vs. 42.9 vs. 40.0 %; no recurrence: 21.1 vs. 14.3 vs. 20.0 %; p = 0.836).

Conclusions

The three approaches have similar outcomes in terms of survival, complication, and recurrence. Effective adjuvant treatments need to be developed to counteract the high incidence of recurrence.     

门静脉癌栓与血栓的超声造影研究

目的探讨超声造影对门静脉癌栓和血栓的鉴别诊断价值。方法应用超声造影剂（SonoVue）对16例门静脉癌栓及8例门静脉血栓行实时低机械指数超声造影，观察并分析其造影增强特征。结果16例癌栓超声造影动脉相10例呈整体均匀性增强，2例呈整体不均匀性增强，2例呈整体轻度增强，2例栓子一部分增强，另一部分无增强；门脉相特别是门脉相晚期和延迟相14例栓子呈充盈缺损状态，2例栓子仍呈轻微强化。4例常规彩超检查未能检出动脉血流信号而不能确诊的癌栓．超声造影均显示其动脉相增强。8例血栓行超声造影后整个造影过程栓子均未见增强。结论超声造影可敏感地反映门静脉栓子的血流灌注，门静脉癌栓和血栓在超声造影后有显著的特征，有助于两者的鉴别诊断。     

Primary Pancreatic Ewing's Sarcoma with Portal Vein Tumor Thrombosis

Background

Extraosseous Ewing's sarcoma (EES) is a mesenchyme-derived small blue cell tumor, which is distinguished by its rarity, aggressiveness, dismal prognosis, and distinct pathogenesis. Occurring almost exclusively among children and young adults, EES can arise from a variety of organs and portends a rapid clinical deterioration and high likelihood of recurrence.

Discussion

We present the first reported case of a primary pancreatic Ewing's sarcoma in a patient with concomitant portal vein thrombosis. The atypical presentation of this extraordinarily rare tumor underscores the imperative to maintain EES in the differential diagnosis of suspicious, indistinct pancreatic lesions in young patients. In addition, we review the available literature describing additional cases of primary pancreatic Ewing's sarcoma.     

Transarterial Chemoembolization for Unresectable Hepatocellular Carcinoma with Portal Vein Tumor Thrombosis: A Prospective Comparative Study

Background

For patients with hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT), the survival benefit of transarterial chemoembolization (TACE) compared with conservative treatment largely remains controversial. The objective of this study was to determine whether TACE confers a survival benefit to patients with HCC and PVTT, and to uncover prognostic factors.

Methods

Between July 2007 and July 2009, a prospective two-arm nonrandomized study was performed on consecutive patients with unresectable HCC with PVTT. In one arm, patients were treated by TACE using an emulsion of lipiodol and anticancer agents ± gelatin sponge embolization. In another arm, patients received conservative treatment.

Results

A total of 164 patients were recruited for the study (TACE group, n = 84; conservative treatment group, n = 80). Patients in the TACE group received a mean of 1.9 (range, 1–5) TACE sessions. The overall median survival for all patients was 5.2 months, and the 12- and 24-month overall survival rates were 18.3% and 5.6%, respectively. The 12- and 24-month overall survival rates for the TACE and conservative groups were 30.9%, 9.2%, and 3.8%, 0%, respectively. The TACE group had significantly better survivals than the conservative group (P < 0.001). On subgroup analysis of segmental and major PVTT, the TACE group also had significantly better survivals (P = 0.002, P = 0.002). The treatment type, PVTT extent, tumor size, and serum bilirubin were independent prognostic factors of survival on multivariate analysis.

Conclusions

TACE was safe and feasible in selected HCC patients with PVTT and it had survival benefit over conservative treatment.     

Efficacy of Postoperative Transarterial Chemoembolization and Portal Vein Chemotherapy for Patients with Hepatocellular Carcinoma Complicated by Portal Vein Tumor Thrombosis—a Randomized Study

Objectives The aim of this single, randomized study was to explore the efficacy of postoperative transarterial chemoembolization (TACE) and portal vein chemotherapy (PVC) for patients with hepatocellular carcinoma (HCC) complicated by portal vein tumor thrombosis (PVTT) and to evaluate prognostic factors. Methods The study cohort consisted of 112 patients with HCC and PVTT randomly divided into three groups: Group A (37 patients), operation only; Group B (35 patients), operation plus TACE; Group C (40 patients), operation plus TACE and PVC. Disease-free survival rates and prognostic factors were analyzed. Results Most of the side effects and complications were related to the operation, catheters, and local chemotherapy and included liver decompensation (15.0%), catheter obstruction (11.6%), and nausea and loss of appetite (22.1%). The disease-free survival curve was significantly different among the three groups, as estimated by the Kaplan-Meier method (both P < 0.05). Group C showed a significantly higher disease-free survival rate than Group A (P < 0.05), but no statistical differences were found between group A and group B, and group B and group C (both P > 0.05). Tumor size, tumor number, PVTT location, and treatment modalities were independent prognostic factors (P < 0.05). Conclusion Postoperative TACE combined with PVC may benefit the survival of patients with HCC complicated by PVTT in the short-term (less than 60 months), but long-term efficacy is not yet certain and needs to be confirmed by further studies.     

Surgical Treatment of Hepatocellular Carcinoma with Portal Vein Tumor Thrombus

Background  

The role of liver resection in patients with hepatocellular carcinoma (HCC) accompanying with portal vein tumor thrombus (PVTT) remains controversial. This article aimed to evaluate the significance of different location and extent of PVTT on surgical outcomes after liver resection for HCC.     

肝细胞癌合并门静脉癌栓组织中PDGF和survivin表达的意义

目的探讨血小板源性生长因子(PDGF)和凋亡抑制基因survivin在肝细胞癌合并门静脉癌栓组织中的表达及其与肝细胞癌细胞增殖之间的关系。方法应用原位杂交技术检测16例肝细胞癌合并门静脉癌栓组织中PDGFmRNA的表达,并与无门静脉癌栓者进行对照;应用免疫组化方法检测36例肝细胞癌合并门静脉癌栓组织中PDGF和survivin蛋白的表达及其相互关系,同时应用流式细胞仪检测肝细胞癌细胞的增殖情况及其分别与PDGF和survivin蛋白表达的关系。结果16例肝细胞癌合并门静脉癌栓组织中PDGFmRNA的表达量为0.1309±0.0146,显著高于无门静脉癌栓者的0.0684±0.0052(P<0.01);PDGF和survivin蛋白表达呈正相关关系(r=0.750,P<0.01);PDGF和survivin蛋白表达阳性组者的肝细胞癌细胞增殖显著高于表达阴性者(P<0.01)。结论肝细胞癌合并门静脉癌栓组织中存在PDGF和survivin基因的过度表达,且两者呈正相关关系;随着两基因表达的增强,肝细胞癌细胞增殖显著增高。     

Surgical Resection Versus Transarterial Chemoembolization for Hepatocellular Carcinoma with Portal Vein Tumor Thrombosis: A Propensity Score Analysis

Background

The long-term survival in hepatocellular carcinoma (HCC) patients with portal vein tumor thrombosis (PVTT) who received surgical resection (SR) or transarterial chemoembolization (TACE) remains unclear. We compared the efficacy of SR and TACE by using a propensity score analysis.

Methods

A total of 247 and 181 HCC patients with PVTT undergoing SR and TACE, respectively, were evaluated. One hundred eight pairs of matched patients were selected from each treatment arm by using a propensity score analysis.

Results

Of all patients, the estimated 1-, 3-, and 5-year survival rates of patients receiving SR and TACE were 85 versus 60 %, 68 versus 42 %, and 61 versus 33 %, respectively (p < 0.001). Patients selected for SR were significantly younger and had better liver functional reserve, performance status, and smaller tumor burden. In the propensity model, the survival benefit of SR remained significant. The estimated 1-, 3-, and 5-year survival rates of patients receiving SR and TACE were 84 versus 71 %, 69 versus 50 %, and 59 versus 35 %, respectively (p = 0.004). The two groups of patients in the propensity score analysis were similar in baseline characteristics. In the Cox proportional hazards model, patients receiving TACE had a 2.044-fold increased risk of mortality compared with patients receiving SR (95 % confidence interval: 1.284–3.252, p = 0.003).

Conclusions

For either unselected patients or patients in the propensity model, SR provides significantly better long-term survival than TACE. SR should be considered as a priority treatment in this subgroup of HCC patients.