一、概述 根据中国国家癌症中心发布的数据,2022年全国原发性肝癌发病人数36.77万,位列各种癌症新发病人数第4位(肺、结直肠、甲状腺、肝),发病率位列第5位(肺、女性乳腺、甲状腺、结直肠、肝);2022年因原发性肝癌死亡人数31.65万,死亡人数和死亡率均位列第2位(肺、肝)[1-2].原发性肝癌主要包括肝细胞癌(hepatocellular carcinoma,HCC)、肝内胆管癌(intrahepatic cholangiocarcinoma,ICC)和混合型肝细胞癌-胆管癌(combined hepatocellular-cholangiocarcinoma,cHCC-CCA)3 种不同病理学类型,三者在发病机制、生物学行为、病理组织学、治疗方法以及预后等方面差异较大,其中HCC占75％～85％、ICC占10％～15％[3-4].本指南中的"肝癌"仅指HCC.
Objective:To explore the best method of monitoring during hepatectomy by Meta-analysis. Methods:From inception to December 13,2022,The electronic databases of PubMed,Web of Science,Embase,CNKI and the Cochrane Library were searched.Randomized clinical trials reporting outcomes with comparison between stroke volume variation(SVV)guided goal-directed fluid therapy and low central venous pressure(LCVP)guided fluid therapy during liver surgery were included by inclusion and exclusion criteria.The perioperative data was statistically summarized using Review Manager 5.3 software. Results:A total of 10 randomized clinical trials were included,with a total sample size of 702 cases,including 354 cases(50.4%)in SVV group and 348 cases(49.6%)in LCVP group.The results of Meta-analysis showed that the arterial lactate concentration in the SVV group was significantly lower than that in the LCVP group,with a statistically significant difference between the two groups(weighted mean difference =-0.84 mmol/L,95%CI:-1.43 mmol/L to-0.25 mmol/L,P=0.005).The reduce intraoperative bleeding and the incidence of total complications without statistically significant differences(all P>0.05).There were no significant differences in surgical field,postoperative biochemical indexes,incidence of serious complications,incidence of postoperative acute renal injury,and length of hospital stay between the two groups(all P>0.05). Conclusion:The use of SVV directed fluid therapy in liver surgery is safe,does not lead to prolonged operative time,increased intraoperative bleeding,or decreased surgical field quality,and significantly reduces intraoperative lactate concentration in patients undergoing hepatectomy.
目的:探索放射治疗(简称放疗)联合免疫检查点抑制剂(PD-1 抑制剂)及仑伐替尼治疗合并门静脉主干或一级分支瘤栓的肝细胞癌(HCC)患者的疗效及安全性. 方法:选取 2018 年 3 月至 2020 年 10 月北京清华长庚医院收治的不可切除且未接受过系统治疗的巴塞罗那临床肝癌分期(BCLC)C 期的HCC,且伴Vp3、Vp4 型门静脉癌栓(PVTT)患者.研究终点主要为3年总生存(OS)率、无进展生存(PFS)率及PVTT的客观有效率.采用Kaplan-Meier生存分析和log-rank检验. 结果:共 47 例患者入组,其中 39 例为Vp4 型PVTT.全组中位随访时间 33.9个月(3.1～57.1 个月),中位OS期为 11.9 个月(95%CI为 7.5～16.3 个月),3 年OS率为 18%;中位PFS期为 5 个月(95%CI为 3.5～6.5 个月),3 年PFS率为 10%.Vp4 型患者中位OS期为 9.4 个月(95%CI为 8.3～10.5 个月),3 年OS率为 13%,中位PFS期为 4.9 个月(95%CI为 3.2～6.6 个月),3 年PFS率为 9%.PVTT客观有效率为 75%.全组无 3 级以上不良反应发生. 结论:放疗联合PD-1 抑制剂及仑伐替尼对合并门静脉主干或一级分支瘤栓的HCC患者远期疗效较好且不良反应可控,该三联疗法可能成为BCLC C期HCC治疗的优选方法之一.
肝细胞癌(hepatocellular carcinoma,HCC)是严重威胁我国人民健康的疾病之一,其发病率居恶性肿瘤第4位,病死率居恶性肿瘤第2位.虽然手术切除是HCC患者获得长期生存的最佳手段,但由于我国HCC患者在诊断时大多已经是中晚期,仅有15%～30%的患者适合手术切除,更多的患者仅适合非手术治疗,5年生存率仅为14. 1%.
结直肠癌肝转移具有极其特殊的生物学特性,肝转移灶的手术切除可以给患者带来明显的生存获益,20%左右手术切除的患者可以获得治愈.近年,随着结直肠癌肝转移外科治疗研究的深入和经验的积累,肝转移灶的手术切除越来越积极,肝转移灶的数目、大小、发生的时间,甚至合并肝外转移,这些因素已经不是肝转移灶手术切除的禁忌.对于不可手术切除的肝转移灶,应该积极地选择强效的转化治疗进行转化,对于转化治疗有效的患者,应该在合适的时机进行手术切除或者手术切除联合射频消融术/立体定向放射治疗.
