不可切除的消化道恶性肿瘤肝转移癌射频消融治疗30例临床分析

近年来影像引导下经皮肝脏穿刺射频消融(RFA)技术在治疗消化道肿瘤肝转移癌方面因靶向精准、创伤小、副作用小、治疗可重复、病灶毁损完全等优点,在肝脏转移癌治疗中的地位越发重要[1].本文回顾性分析了5年来因发现不可切除的消化道肿瘤肝转移癌在影像学引导下行RFA治疗后疗效、并发症及生存情况.     

射频消融联合化疗治疗结直肠癌肝转移22例

[目的]观察射频消融(RFA)联合化疗治疗结直肠癌肝转移的疗效。[方法]对22例不能手术的结直肠癌肝转移患者行经皮穿刺RFA及FOLFOX4化疗。[结果]22例57个病灶,完全坏死率81.82%,对坏死的判断,CT优于超声,中位无局部复发时间为232 d,中位生存期27个月,1年及2年生存率分别为91.2%及74.8%。[结论]RFA联合化疗治疗结直肠癌肝转移安全有效,值得进一步探索研究。     

腹腔镜联合射频消融和125I粒子治疗肝转移癌

目的探讨腹腔镜切除并联合应用射频消融和^125I粒子植入治疗肝转移癌的临床价值。方法对62例术前经CT或MR确诊肝脏有转移灶的患者，行腹腔镜下肝转移瘤切除或射频消融，最后将^125粒子植入肝脏肿瘤部位。结果术中超声发现新病灶17个，所有患者均顺利行腹腔镜切除或射频消融及^125粒子植入。2例术后出现肝脓肿，1例术后发生腹腔少量出血，余无严重并发症。^125个转移病灶位于肝脏右后内叶或巨大仅行腹腔镜下射频消融及^125粒子植入，22例患者的38个边缘转移病灶行离体切除。随访12～25个月（平均22．3个月），有12例转移癌未见液化，行腹腔镜下二次射频及^125粒子植入。1年生存率为74．2％（46／62），2年生存率为59．7％（37／62）。结论腹腔镜切除并联合应用射频消融和^125粒子植入治疗肝转移癌具有微创、安全、有效，术后恢复快等优点。     

安替可胶囊联合实时虚拟导航系统引导射频消融治疗不可切除的直肠癌肝转移患者疗效初步研究

目的 探讨安替可胶囊联合实时虚拟导航系统引导下射频消融治疗不可切除的直肠癌肝转移患者的临床疗效。方法 2013年1月～2014年1月我院收治的74例无法手术切除的直肠癌肝转移患者,37例在实时虚拟导航系统引导下行射频消融和FOLFOX6方案化疗,37例观察组在上述治疗的基础上同时给予安替可胶囊口服治疗。采用实体瘤疗效评价标准评价近期疗效,观察两组无疾病进展生存时间（PFS）和生存率。结果 观察组近期疗效总有效率为78.4%,明显高于对照组的62.2%（P<0.05）;两组1 a生存率分别为89.2%和83.8%,而观察组2 a生存率则显著高于对照组（67.5%对54.1%,P<0.05）;观察组中位PFS 为12.4个月（95%可信区间为10.0～16.2）,明显长于对照组的10.1个月,差异具有统计学意义（P＜0.05）。结论 对外科手术不可切除的直肠癌肝转移患者,在实时虚拟导航系统引导下行射频消融治疗,术后给予安替可胶囊口服,疗效确切,安全性较高。     

超声造影在肝癌肝移植术后肝转移癌射频消融治疗之中的应用

目的通过临床总结,评价超声造影(CEUS)在射频消融治疗肝癌肝移植术后肝转移癌中应用的优点。方法采用超声造影辅助诊断定位经皮穿刺射频消融(RFA)治疗肝癌肝移植术后2～12月肝转移癌灶12例,癌灶直径12 mm～45 mm,每个病灶通过超声造影诊断定位进行RFA 1～2次,术后通过超声造影及增强CT评价疗效。结果11例病灶术后1月后复查,示全部消融,1例较大病灶治疗后有部分残余,行再次射频,1月后复查病灶坏死。结论超声造影应用于RFA治疗肝癌肝移植术后肝转移癌发现早,诊断早,定位准确,效果好,操作简便易行,微创无严重并发症,进一步提高了超声引导下RFA的准确率和疗效。     

射频消融联合化疗治疗结直肠癌肝转移的非随机对照研究

目的观察射频消融联合化疗方案治疗结直肠癌肝转移的客观疗效和生存受益。方法采用非随机对照研究的方法，51位符合入选标准的患者按治疗意愿分为对照组（单纯化疗）32例和试验组（射频联合化疗）19例：对照组采用FOLFOX或FOLFIRI方案，试验组采用化疗-射频消融-化疗的夹心疗法，化疗方案同对照组。研究终点包括客观有效率、疾病控制率和中位肿瘤进展时间（mTTP）、中位生存期（MST）和临床受益反应。结果试验组和对照组的客观有效率分别为36．8％（7／19）和25．0％（8/32）（P〉0．05）；疾病控制率分别为94．7％（18/19）和68．8％（22/32）（P〈0．05）；mTTP分别为285d和191d（P〈0．01），MST分别为693d和387d（P〈0．01）；临床受益反应分别为89．5％（17／19）和65．6％（21/32）（P〉0．05）。结论射频消融结合化疗治疗结直肠癌肝转移可明显提高结直肠癌肝转移患者的生存期，是一种有临床应用前景的姑息性治疗方法。     

射频消融合并化疗泵植入治疗大肠癌异时性肝转移的疗效

大肠癌最常见的转移部位为肝脏,且肝转移为本病的重要致死因素。初诊病例中有20%～25%已发生肝转移,原发灶切除后仍有20%～25%发生肝转移〔1〕。本文对我院2004年1月1日至2011年8月1日收治的31例大肠癌术后肝转移患者同时进行射频消融(RFA)及门静脉化疗泵植入,观察临床效果。     

手术切除与射频消融治疗原发性肝癌患者预后比较

目的 比较手术切除与射频消融（RFA）治疗原发性肝癌患者预后比较。方法 2009年7月~2011年12月我院收治的原发性肝癌患者218例,其中106例实施手术切除肿瘤,另外112例实施RFA。比较两种不同方法治疗患者的预后情况。结果 两组患者病灶清除率均为100%,但RFA组术中无输血患者,而4.7%手术组患者术中实施了输血（P<0.05）,RFA组平均治疗时间为（30.5±7.4）min,平均住院时间为（7.3±0.9）d,均短于手术组的（146.2±30.4）min和（12.4±2.7）d （P<0.05）;RFA组发生胸腔/腹腔积液比例为15.2%,血红蛋白（Hb）≤90g/L比例为15.2%,血清白蛋白（ALB）≤30g/L比例为17.0%,三种并发症比例均低于手术组（31.1%、35.8%和36.8%,均P<0.05）;两组围术期出现体温>38℃患者比例和腹腔感染发生率差异无统计学意义;术后三个月经增强MRI检查两组患者病灶消失情况,显示5.4%RFA组患者存在病灶残留,手术组无病灶残留患者（P<0.05）,RFA组病灶复发比例为9.8%,显著高于手术组的1.9%（P<0.05）;RFA组1 a、3 a和5 a生存率分别为92.9%、39.3%和17.9%,而手术组为97.2%、56.6%和29.2%,其中3 a和5 a生存率存在组间显著差异（P<0.05）;RFA组1 a、3 a和5 a复发转移率分别为39.3%、69.6%和98.2%,而手术组为29.2%、51.9%和86.8%,其中3 a和5 a复发转移率存在组间显著差异（均P<0.05）。结论 RFA治疗原发性肝癌可缩短手术时间,减少并发症发生,但容易有病灶残留,患者长期预后较手术组稍差。     

手术切除与射频消融治疗小肝癌的疗效比较

目的比较小肝癌手术切除与射频消融（RFA）初治后疗效及复发情况。方法收集吉林大学白求恩第一医院2002年1月至2008年12月接受手术或RFA初治的97例小肝癌患者资料,并对治疗后满2年的患者进行随访,共随访到63例,手术和RFA治疗分别为34和29例,回顾性分析两种方法治疗小肝癌患者的预后复发情况。计量资料采用χ2检验,利用Cox回归分析比较影响患者复发相关的危险因素,并应用Log-rank进行两种无瘤生存率检验。结果手术与射频消融治疗小肝癌3个月、1、2 a复发率分别15%、38%、64%,21%、35%、45%,两者差异无统计学意义。初治后复发与治疗方法、性别、年龄、Child-Pugh分级、肿瘤大小、结节数目、是否合并有肝硬化、甲胎蛋白水平相关性差异无统计学意义,两者无瘤生存率差异无统计学意义。结论 RFA与肝癌切除术在治疗小肝癌取得相近的治疗效果,RFA有望成为替代手术治疗的一种理想的治疗方法。     

Unexplained liver laceration after metastasis radiofrequency ablation

Many studies have established the role of radiofrequency (RF) ablation as a minimally invasive treatment for liver metastases. Although relatively safe, several complications have been reported with the increased use of RF ablation. We describe here a case of unexplained liver laceration after a RF procedure. A woman who presented a solitary metachronous liver metastasis underwent RF ablation treatment for this lesion. Six hours later the patient displayed fatigue and pallor.Emergency blood tests showed a haemoglobin level of < 7 g/dL and markedly elevated transaminase levels.A computed tomography examination revealed two areas of liver laceration with haematoma, one of them following the path of the needle and the other leading away from the first. Following a blood transfusion, the patient was haemodynamically stable and completely recovered 24 h later. The patient remained in bed for 1 wk. No surgical intervention was required, and she was discharged 1 wk later.     

Lymphocyte-to-monocyte ratio predicts survival after radiofrequency ablation for colorectal liver metastases

AIM: To test the correlation between lymphocyte-tomonocyte ratio(LMR) and survival after radiofrequency ablation(RFA) for colorectal liver metastasis(CLMs). METHODS: From July 2003 to Feb 2012, 127 consecutive patients with 193 histologically-proven unresectable CLMs were treated with percutaneous RFA at the University of Foggia. All patients had undergone primary colorectal tumor resection before RFA and received systemic chemotherapy. LMR was calculated by dividing lymphocyte count by monocyte count assessed at baseline. Treatment-related toxicity was defined as any adverse events occurred within 4 wk after the procedure. Overall survival(OS) and time to recurrence(TTR) were estimated from the date of RFA by Kaplan-Meier with plots and median(95%CI). The inferential analysis for time to event data was conducted using the Cox univariate and multivariate regression model to estimate hazard ratios(HR) and 95%CI. Statistically significant variables from the univariate Cox analysis were considered for the multivariate models.RESULTS: Median age was 66 years(range 38-88) and patients were prevalently male(69.2%). Median LMR was 4.38%(0.79-88) whereas median number of nodules was 2(1-3) with a median maximum diameter of 27 mm(10-45). Median OS was 38 mo(34-53) and survival rate(SR) was 89.4%, 40.4% and 33.3% at 1, 4 and 5 years respectively in the whole cohort. Running log-rank test analysis found 3.96% as the most significant prognostic cut-off point for LMR and stratifying the study population by this LMR value median OS resulted 55 mo(37-69) in patients with LMR 3.96% and 34(26-39) mo in patients with LMR ≤ 3.96%(HR = 0.53, 0.34-0.85, P = 0.007). Nodule size and LMR were the only significant predictors for OS in multivariate analysis. Median TTR was 29 mo(22-35) with a recurrence-free survival(RFS) rate of 72.6%, 32.1% and 21.8% at 1, 4 and 5 years, respectively in the whole study group. Nodule size and LMR were confirmed as significant prognostic factors for TTR in multivariate Cox regression. TTR, when stratified by LMR, was 35 mo(28-57) in the group 3.96% and 25 mo(18-30) in the group ≤ 3.96%(P = 0.02).CONCLUSION: Our study provides support for the use of LMR as a novel predictor of outcome for CLM patients.     

Bipolar radiofrequency ablation of liver metastases during laparotomy. First clinical experiences with a new multipolar ablation concept

Background and objective Radiofrequency ablation (RFA) is a promising method for local treatment of liver malignancies. Currently available systems for radiofrequency ablation use monopolar current, which carries the risk of uncontrolled electrical current paths, collateral damages and limited effectiveness. To overcome this problem, we used a newly developed internally cooled bipolar application system in patients with irresectable liver metastases undergoing laparotomy. The aim of this study was to clinically evaluate the safety, feasibility and effectiveness of this new system with a novel multipolar application concept.Patients and methods Patients with a maximum of five liver metastases having a maximum diameter of 5 cm underwent laparotomy and abdominal exploration to control resectability. In cases of irresectability, RFA with the newly developed bipolar application system was performed. Treatment was carried out under ultrasound guidance. Depending on tumour size, shape and location, up to three applicators were simultaneously inserted in or closely around the tumour, never exceeding a maximum probe distance of 3 cm. In the multipolar ablation concept, the current runs alternating between all possible pairs of consecutively activated electrodes with up to 15 possible electrode combinations. Post-operative follow-up was evaluated by CT or MRI controls 24–48 h after RFA and every 3 months.Results In a total of six patients (four male, two female; 61–68 years), ten metastases (1.0–5.5 cm) were treated with a total of 14 RF applications. In four metastases three probes were used, and in another four and two metastases, two and one probes were used, respectively. During a mean ablation time of 18.8 min (10–31), a mean energy of 48.8 kJ (12–116) for each metastases was applied. No procedure-related complications occurred. The patients were released from the hospital between 7 and 12 days post-intervention (median 9 days). The post-interventional control showed complete tumour ablation in all cases.Conclusions Bipolar radiofrequency using the novel multipolar ablation concept permits a safe and effective therapy for the induction of large volumes of coagulation in the local treatment of liver metastases.     

Aggressive liver resection including major-vessel resection for colorectal liver metastases

AIM: To clarify short- and long-term outcomes of combined resection of liver with major vessels in treating colorectal liver metastases.METHODS: Clinicopathologic data were evaluated for 312 patients who underwent 371 liver resections for metastases from colorectal cancer. Twenty-five patients who underwent resection and reconstruction of retrohepatic vena cava, major hepatic veins, or hepatic venous confluence during hepatectomies were compared with other patients, who underwent conventional liver resections.RESULTS: Morbidity was 20% (75/371) and mortality was 0.3% (1/312) in all patients after hepatectomy. Hepatic resection combined with major-vessel resection/reconstruction could be performed with acceptable morbidity (16%) and no mortality. By multivariate analysis, repeat liver resection (relative risk or RR, 5.690; P = 0.0008) was independently associated with resection/reconstruction of major vessels during hepatectomy, as were tumor size exceeding 30 mm (RR, 3.338; P = 0.0292) and prehepatectomy chemotherapy (RR, 3.485; P = 0.0083). When 312 patients who underwent a first liver resection for initial liver metastases were divided into those with conventional resection (n = 296) and those with combined resection of liver and major vessels (n = 16), overall survival and disease-free rates were significantly poorer in the combined resection group than in the conventional resection group (P = 0.02 and P < 0.01, respectively). A similar tendency concerning overall survival was observed for conventional resection (n = 37) vs major-vessel resection combined with liver resection (n = 7) performed as a second resection following liver recurrences (P = 0.09). Combined major-vessel resection at first hepatectomy (not performed; 0.512; P = 0.0394) and histologic major-vessel invasion at a second hepatectomy (negative; 0.057; P = 0.0005) were identified as independent factors affecting survival by multivariate analysis.CONCLUSION: Hepatic resection including major-vessel resection/reconstruction for colorectal liver metastases can be performed with acceptable operative risk. However, such aggressive approaches are beneficial mainly in patients responding to effective prehepatectomy chemotherapy.     

Referral patterns of patients with liver metastases due to colorectal cancer for resection

Introduction  Colorectal carcinoma accounts for 10% of cancer deaths in the Western World, with the liver being the most common site of distant metastases. Resection of liver metastases is the treatment of choice, with a 5-year survival rate of 35%. However, only 5–10% of patients are suitable for resection at presentation. Aims  To examine the referral pattern of patients with liver metastases to a specialist hepatic unit for resection. Methodology  Retrospective review of patient’s charts diagnosed with colorectal liver metastases over a 10-year period. Results  One hundred nine (38 women, 71 men) patients with liver metastases were included, mean age 61 years; 79 and 30 patients had synchronous and metachronus metastases, respectively. Ten criteria for referral were identified; the referral rate was 8.25%, with a resection rate of 0.9%. Forty two percent of the patients had palliative chemotherapy; 42% had symptomatic treatment. Conclusion  This study highlights the advanced stage of colorectal cancer at presentation; in light of modern evidence-based, centre-oriented therapy of liver metastasis, we conclude that criteria of referral for resection should be based on the availability of treatment modalities.     

Comparative analysis of radiofrequency ablation and resection for resectable colorectal liver metastases

AIM:To evaluate the therapeutic efficacy of radiofrequency ablation(RFA)for resectable colorectal liver metastases(CRLM)compared with that of resection.METHODS:Between June 2004 and June 2009,we retrospectively analyzed 29 patients with resectable CRLMs;17 patients underwent RFA,and 12 underwent hepatic resection.All of the patients were informed about the treatment modalities and were allowed to choose either of them.RFA including an intraoperative approach was performed by a radiologist;otherwise,hepatic resection was performed by a surgeon.Comparative analysis of the two groups was performed,including comparisons of gender,age,and clinical outcomes,such as primary tumor stage and survival rates.RESULTS:The mean tumor size was significantly larger in the resection group(3.59 cm vs 2.02 cm,P<0.01),and the 5-year overall survival(OS)rate for all patients was 44.7%.There was no difference in the 5-year OS rates between the RFA and resection groups(37.8%vs66.7%).Univariate analysis indicated significantly lower5-year OS rates for patients with a tumor size>3cm.The 5-year disease-free survival(DFS)rates were17.6%and 22.2%in the RFA and resection groups,respectively(P=0.119).Univariate analysis revealed that in cases of male gender,age>65 years,T stage<Ⅳ,absence of lymphatic metastasis,and tumor size>3 cm,RFA resulted in significantly inferior 5-year DFS rates compared with surgical resection.CONCLUSION:Surgical resection revealed superior outcomes in the treatment of resectable CRLMs,particularly in cases with a hepatic tumor size>3 cm.     

结直肠癌肝转移的危险因素分析138例

目的:探讨影响结直肠癌肝转移的危险因素.方法:采用Kaplan-Meier和多因素回归分析方法,分析138例有完整随访资料的结直肠癌肝转移患者的生存情况及影响预后的相关因素.结果:138例患者的中位生存时间为18.3mo.单因素分析显示,患者年龄(P=0.460)、原发肿瘤部位(P=0.568)、原发肿瘤最大直径(P=0.250)、原发肿瘤组织学分级(P=0.589)与患者的总生存时间无关,而性别(P=0.048)、治疗前血清CEA水平(P=0.023)、肝转移灶数目(P=0.000)、肝转移灶最大直径(P=0.001)、区域淋巴结转移情况(P=0.001)、肝转移灶手术与否(P=0.002)与患者的预后有关.多因素回归分析显示,治疗前血清CEA水平(P=0.028)、肝转移灶数目(P=0.001)、肝转移灶最大直径(P=0.001)、区域淋巴结转移情况(P=0.049)、肝转移灶手术与否(P=0.003)是影响结直肠癌肝转移患者预后的主要因素.结论:治疗前血清CEA水平、肝转移灶数目、肝转移灶最大直径、区域淋巴结转移情况、肝转移灶手术与否是结直肠癌肝转移患者预后的影响因素;治疗前血清CEA水平越低、肝转移灶数目越少、肝转移灶最大直径越小、无区域淋巴结转移、肝转移灶通过手术治疗的患者预后越好.     

Radiofrequency ablation vs hepatic resection for solitary colorectal liver metastasis: a meta-analysis

AIM:To evaluate the comparative therapeutic efficacy of radiofrequency ablation (RFA) and hepatic resection (HR) for solitary colorectal liver metastases (CLM).METHODS:A literature search was performed to identify comparative studies reporting outcomes for both RFA and HR for solitary CLM.Pooled odds ratios (OR) with 95% confidence intervals (95% CI) were calculated using either the fixed effects model or random effects model.RESULTS:Seven nonrandomized controlled trials studies were included in this analys...     

Multi-modality treatment of colorectal liver metastases

Liver metastases synchronously or metachronously occur in approximately 50% of colorectal cancer patients. Multimodality comprehensive treatment is the best therapeutic strategy for these patients. However, the optimal pattern of multimodality therapy is still controversial, and it raises several significant concerns. Liver resection is the most important treatment for colorectal liver metastases. The definition of resectability has shifted to focus on the completion of R0 resection and normal liver function maintenance. The role of neoadjuvant and adjuvant chemotherapy still needs to be clarified. The management of either progression or complete remission during neoadjuvant chemotherapy is challenging. The optimal sequencing of surgery and chemotherapy in synchronous colorectal liver metastases patients is still unclear. Conversional chemotherapy, portal vein embolization, two-stage resection, and tumor ablation are effective approaches to improve resectability for initially unresectable patients. Several technical issues and concerns related to these methods need to be further explored. For patients with definitely unresectable liver disease, the necessity of resecting the primary tumor is still debatable, and evaluating and predicting the efficacy of targeted therapy deserve further investigation. This review discusses different patterns and important concerns of multidisciplinary treatment of colorectal liver metastases.     

Computer planned,image-guided combined resection and ablation for bilobar colorectal liver metastases

For patients with extensive bilobar colorectal liver metastases (CRLM), initial surgery may not be feasible and a multimodal approach including microwave ablation (MWA) provides the only chance for prolonged survival. Intraoperative navigation systems may improve the accuracy of ablation and surgical resection of so-called “vanishing lesions”, ultimately improving patient outcome. Clinical application of intraoperative navigated liver surgery is illustrated in a patient undergoing combined resection/MWA for multiple, synchronous, bilobar CRLM. Regular follow-up with computed tomography (CT) allowed for temporal development of the ablation zones. Of the ten lesions detected in a preoperative CT scan, the largest lesion was resected and the others were ablated using an intraoperative navigation system. Twelve months post-surgery a new lesion (Seg IVa) was detected and treated by trans-arterial embolization. Nineteen months post-surgery new liver and lung metastases were detected and a palliative chemotherapy started. The patient passed away four years after initial diagnosis. For patients with extensive CRLM not treatable by standard surgery, navigated MWA/resection may provide excellent tumor control, improving longer-term survival. Intraoperative navigation systems provide precise, real-time information to the surgeon, aiding the decision-making process and substantially improving the accuracy of both ablation and resection. Regular follow-ups including 3D modeling allow for early discrimination between ablation zones and recurrent tumor lesions.