Objective:To evaluate the efficacy and safety of Tiaogan Lipi granules (TGLPG) on postembolization syndrome (PES) induced by transcatheter arterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC).Methods:This study was a multi-center, randomized, double-blind, placebo-controlled trial. 124 HCC patients were randomly divided into the experimental group and the placebo group at a 1:1 ratio. In the experimental group, the patients received TGLPG in addition to the standard treatment. And in the control group, the patients received the placebo. The PES was measured as the primary outcome, and traditional Chinese medicine (TCM) symptom scale and quality of life were measured as secondary outcomes. The hematological test, renal function, and electrocardiogram were used as the safety index in clinical trials.Results:There was no significant difference between the two groups at baceline. At postoperative day 7, the TCM scale in the study group was significantly improved compared to that in the control group (P < 0.05). The symptoms of PES, including nausea, fever, and pain, were found to be relieved significantly by TGLPG (P < 0.05).Conclusions:TGLPG may be an effective modality to relieve PES and improve the quality of life in patients with HCC after TACE.

目的 总结介入术治疗后并发肿瘤溶解综合征(Tumor lysis syndrome,TLS)的肝细胞癌(Hepatocellular carcinoma,HCC)患者的临床特点,并探讨其有效治疗方法.方法 收集9例介入术治疗后并发TLS的HCC患者临床资料,作回顾性分析,总结其临床特点、诊断及治疗方法.结果 9例HCC患者中7例存在门静脉癌栓,均行介入术治疗,其中肝动脉化疗栓塞术7例、经皮射频消融术1例、肝动脉栓塞联合经皮射频消融术1例,对介入术治疗敏感.术后第2天,3例患者出现24 h尿量＜400 mL,9例患者血清尿素氮、肌酐、尿酸、钾、磷水平均升高,钙及甲胎蛋白水平降低,确诊为TLS,进行静脉补液水化、应用利尿剂、纠正电解质紊乱、连续性肾脏替代治疗,术后第7天血清各项指标均明显好转.结论 肿瘤负荷重、肿瘤对治疗敏感的HCC患者容易并发TLS.尿量减少、肾功能及电解质水平紊乱可诊断TLS.TLS的有效治疗方法为补液、利尿、纠正电解质紊乱、降尿酸及CRRT治疗.

肝细胞癌(hepatocellular carcinoma,HCC)是常见的消化系统恶性肿瘤之一,其具有起病隐袭、早期症状不明显、进展迅速等特点,一经发现已发展至中晚期,给患者生命健康带来严重威胁.近年来,随着新型生物标志物的发现和检测技术的构建与应用,HCC的诊断、疗效及预后评估效果有了显著提升,大大提高了HCC患者生存质量.本文就近年来HCC的诊断、疗效及预后标志物的研究进展作一综述,重点分析HCC不同标志物的功能作用,为HCC标志物的临床应用提供重要依据.

The aim of this study was to propose a stem cell therapy for hepatitis B virus (HBV)-related acute-on-chronic liver failure (ACLF) based on plasma exchange (PE) for peripheral blood stem cell (PBSC) collection and examine its safety and efficacy. Sixty patients (n=20 in each group) were randomized to PE (PE alone), granulocyte colony-stimulating factor (G-CSF) (PE after G-CSF treatment), and PBSC transplantation (PBSCT) (G-CSF, PE, PBSC collection and hepatic artery injection) groups. Patients were followed-up for 24 weeks. Liver function and adverse events were recorded. Survival analysis was performed. PBSCT improved blood ammonia levels at 1 week (P<0.05). The level of total bilirubin, international normalized ratio, and creatinine showed significant differences in the 4th week of treatment (P<0.05). The survival rates of the PE, G-CSF, and PBSCT groups were 50, 65, and 85% at 90 days (P=0.034). There was a significant difference in 90-day survival between the PE and PBSCT groups (P=0.021). The preliminary results suggested that PBSCT was safe, with a possibility of improved 90-day survival in patients with HBV-ACLF.

目的 探讨经导管肝动脉化疗栓塞术(transcatheter arterial chemoembolization,TACE)联合经皮射频消融术(radiofrequency ablation,RFA)治疗早、中期肝细胞癌(hepatocellular carcinoma,HCC)的疗效及预后影响因素.方法 选取解放军总医院第五医学中心2016年9月至2018年3月明确诊断的120例早、中期HCC患者为研究对象,依照患者意愿分为TACE组(60例)和TACE+RFA组(60例),记录患者肝脏基础疾病、Child-Pugh分级及肿瘤BCLC分期等一般资料.并于术前、术后1个月和3个月检测血甲胎蛋白(alpha-fetoprotein,AFP)、癌胚抗原(carcinoembryonic antigen,CEA)、糖类抗原199(carbohydrate antigen199,CA-199)、糖类抗原-125(carbohydrate antigen125,CA-125)、γ-谷氨酰转移酶(gamma-glutamyltranspeptidase,GGT)、白细胞介素(interlukin,IL)-2、IL-4、IL-6、IL-10、γ-干扰素(interferon-γ,INF-γ)及肿瘤坏死因子α(tumor necrosis factor-α,TNF-α)等指标.随访截至2019年3月,采用Kaplan-Meier法计算累计中位总生存期(orerall survival,OS)和无进展生存期(progression free survival,PFS),采用Cox回归模型分析患者OS及PFS的影响因素.结果 术后1个月,TACE+RFA组及TACE组AFP(中位数:8.07μg/L vs 9.59μg/L)、IL-6(中位数:7.61 ng/L vs 15.96 ng/L)及IL-4(中位数:3.87 ng/L vs 5.39 ng/L)差异有统计学意义(P均<0.05).术后3个月,TACE+RFA组及TACE组AFP(中位数:6.67μg/L vs 8.94μg/L)、IFN-γ(中位数:19.08 ng/L vs 21.28 ng/L)、IL-6(中位数:8.37 ng/L vs 18.53 ng/L)及IL-4(中位数:4.06 ng/L vs 5.69 ng/L)差异有统计学意义(P均<0.05).至随访结束,失访6例,病死16例,TACE+RFA组和TACE组总生存率分别为94.8％(55/58)、76.8％(43/56),均未出现致命性的严重并发症.TACE+RFA组OS(17.9个月vs 13.6个月)和PFS(17.3个月vs 7.9个月)均显著长于TACE组(χ2=23.037、35.930,P均<0.001).术后3个月及1年疗效评估,TACE+RFA组客观缓解率(术后3个月:91.67％vs 55.00％,术后1年:63.33％vs 35.00％)和疾病控制率(术后3个月:93.34％vs 65.00％,术后1年:78.33％vs 51.77％)均显著高于TACE组(P均<0.05).Log-Rank单因素分析表明,患者的Child-Pugh分级(B级)、肿瘤BCLC分期(B期)、肿瘤最大直径(≥5 cm)、肿瘤数量(≥3个)及术前AFP水平(≥200μg/L)等对TACE+RFA术后疗效及预后均有显著影响(P均<0.05).Cox多因素分析表明,治疗方法 的选择是影响早、中期HCC患者预后的独立因素(P=0.014).结论 治疗方案的选择是影响早、中期HCC患者术后疗效及预后的影响因素,TACE联合RFA治疗可显著改善早、中期HCC患者疗效,延长OS及PFS.

目的 研究腹部磁共振弥散加权成像应用于肝脏良、恶性肿瘤鉴别中发挥的作用.方法 对2018年7月-2019年2月收治的86例肝脏肿瘤患者,在常规磁共振平扫的基础上,采用腹部磁共振弥散加权成像(DWI)技术对患者实施扫描,观察其应用效果.结果 肝细胞癌患者的表观扩散系数与肝转移瘤患者相比无统计学意义(P＞0.05);肝细胞癌、肝转移瘤患者ADC值均明显低于肝血管瘤患者(P＜0.05);肝细胞癌、肝转移瘤、肝血管瘤患者ADC值均明显低于肝囊肿患者(P＜0.05).结论 腹部磁头振弥散加权成像能够为肝脏良、恶性肿瘤的临床鉴别提供良好参考依据,应用效果显著.

ObjectiveTo investigate the clinical effect and safety of cyberknife versus radiofrequency ablation in the treatment of small hepatocellular carcinoma. MethodsA total of 80 previously untreated patients with small hepatocellular carcinoma who were admitted to The Fifth Medical Center of Chinese PLA General Hospital from October 2017 to March 2018 were enrolled. Among these patients, 35 patients with 41 target lesions received cyberknife, and 45 patients with 47 target lesions received radiofrequency ablation. The two groups were compared in terms of objective response rate (complete remission+partial remission), 1-year overall survival rate, 1-year local control rate, and incidence rate of postoperative adverse events. The chi-square test or the continuous calibration chi-square test was used for comparison of categorical data between groups. The Kaplan-Meier method was used to calculate local control rate, and the log-rank test was used for survival analysis. ResultsThe patients were followed up for 6.0-17.7 months, with a median follow-up time of 13.5 months. Two patients (2.5%) were lost to follow-up, with one patient from each group. In the cyberknife group, there were 31 lesions with complete remission (75.6%), 4 lesions with partial remission (9.8%), 4 lesions with a stable state (9.8%), and 2 lesions with progression (48%), with an objective response rate of 85.4%, a 1-year overall survival rate of 100%, and a 1-year local control rate of 94.3%. In the radiofrequency ablation group, there were 38 lesions with complete remission (80.9%) and 9 lesions with progression (19.1%), with an objective response rate of 80.9%, a 1-year overall survival rate of 100%, and a 1-year local control rate of 91.0%. There were no significant differences in objective response rate and local control rate between the two groups (both P＞0.05). Most postoperative adverse events were mild (grade 1-2), and no serious adverse events were observed. ConclusionCyberknife is as safe and effective as radiofrequency ablation in the treatment of small hepatocellular carcinoma and is one of the options for the treatment of small hepatocellular carcinoma.

目的 分析多个血清标志物联合检测对甲胎蛋白(AFP)阴性原发性肝癌患者经导管肝动脉化疗栓塞术(TACE)治疗后疗效及预后的临床价值.方法 纳入解放军总医院第五医学中心2016年9月至2018年3月接受TACE治疗的120例肝细胞癌(HCC)患者,其中44例AFP水平正常(AFP阴性),76例AFP水平增高(AFP阳性),分别检测患者TACE术前、术后1个月和3个月的血清AFP、癌胚抗原(CEA)、糖类抗原-199(CA199)、CA125、γ-谷氨酰转移酶(GGT)、白细胞介素-2(IL-2)、IL-4、IL-6、IL-10、IFN-γ、TNF-α等指标水平.随访至2018年7月,观察患者肿瘤活性情况,分析不同标志物组合对AFP阴性HCC患者TACE术后疗效及预后的临床价值.结果 AFP阴性和阳性患者术前各项指标水平比较,差异均无统计学意义(P>0.05).IL-6联合GGT检测AFP阴性和阳性HCC患者TACE术后疗效及预后的灵敏度、特异度、阴性预测值、阳性预测值分别为95.2％、87.0％、87.0％、95.2％和85.7％、59.6％、70.1％、79.1％;IL-6对AFP阴性及阳性HCC患者预后的ROC曲线下面积分别为0.839和0.666.结论 血清IL-6联合GGT检测可作为一种预测AFP阴性HCC患者TA C E术后疗效及肿瘤活性的有效指标.

原发性肝癌(primary liver cancer,PLC)是常见恶性肿瘤之一,其发病率在世界恶性肿瘤中排第六位,死亡率居第三位.全世界每年超过70万人被诊断为肝癌,其中约50％来自中国,由于早期没有症状或症状不明显,确诊时大多数患者已经达到晚期或发生远处转移.经导管肝动脉化疗栓塞术 (transcatheter arterial chemoembolization,TACE)治疗是公认的不能手术切除中晚期肝癌的首选治疗方法.TACE在栓塞肿瘤供血动脉的同时,也会使邻近正常或硬化的肝组织血供受到影响,出现肝细胞坏死,严重时会引起肝衰竭,同时化疗药物对局部肝组织也可以造成一定损伤,这些副作用对患者生存期有一定影响[1].因此,对患者TACE术前进行评估,指导是否选择TACE治疗显得尤为重要.

Patients with hepatocellular carcinoma (HCC) exhibit a high incidence of concomitant cirrhosis with leukopenia and/or thrombocytopenia. In the present study, perioperative changes in the white blood cell (WBC) and platelet (PLT) counts and associated complications were investigated to assess the safety of transcatheter arterial chemoembolization (TACE) for HCC patients with preprocedural leukopenia or thrombocytopenia. The records of 1,461 HCC patients who received TACE between January 2012 and December 2013 were retrospectively reviewed. The incidence of complications during the perioperative period and changes in the WBC and PLT counts were recorded. A Chi-squared test was used to evaluate the associations between postoperative infection and preprocedural WBC count and between bleeding at the puncture site and preprocedural PLT count. The WBC count of the majority of the patients increased within 3 days and returned to the preprocedural level within 30 days after TACE. The PLT count decreased within 3 days and returned to the preprocedural level within 30 days after TACE. The major complications were liver decompensation (n=66), puncture site bleeding (n=45), infection (n=33), severe thrombocytopenia (n=8), upper gastrointestinal bleeding (n=6), tumor bleeding (n=4) and agranulocytosis (n=3). A Chi-squared test revealed that postoperative infection was not associated with preprocedural WBC count and puncture site bleeding was not associated with decreased PLT count due to hypersplenism. Therefore, TACE was found to be safe for HCC patients with preprocedural thrombocytopenia or leukopenia due to hypersplenism, with a low incidence of major complications during the perioperative period.

OBJECTIVE:To assess the comparative efficacy and safety of combination treatment with transarterial chemoembolization (TACE) for patients with unresectable hepatocellular carcinoma (HCC) through a systematic review and network meta-analysis and to identify what is the best combination treatment with TACE.MATERIALS AND METHODS:A network meta-analysis was used to identify evidence from relevant randomized controlled trials. We searched databases for publications up to June 2017. The prespecified primary efficacy outcomes were treatment response and 6-month to 3-year overall survival (OS), while the secondary efficacy outcomes were 1- and 2-year disease-free survival (DFS); safety outcomes were advance effects of combination treatment. We conducted pairwise meta-analyses using a random-effects model and then performed random-effects network meta-analyses.RESULTS:A total of 48 trials were eligible (50 analyses), involving 5627 patients and 19 treatment arms. In comparison with other types of combination therapy arms, network meta-analysis disclosed that TACE + three-dimensional conformal radiotherapy, TACE + percutaneous ethanol injection, TACE + percutaneous microwave coagulation therapy, TACE + percutaneous acetic acid injection, and TACE + sorafenib were the more effective methods in treatment response, 6-month to 3-year OS, and 1-2 year DFS; the adverse effects of TACE + sorafenib were serious. The study was registered with PROSPERO, number CRD42017071102.CONCLUSIONS:When considering the efficacy, combination therapy with TACE seemed to offer clear advantages for patients with unresectable HCC. TACE + Three-dimensional conformal radiotherapy, TACE + Percutaneous ethanol injection, TACE + Percutaneous microwave coagulation therapy, and TACE + Percutaneous acetic acid injection are likely the best options to consider in the application of combination treatment.

目的 使用CT评价肝脂肪浸润和腹部脂肪体积的关系.方法 对2013年11月-2015年4月期间在门诊就诊的306位患者测量以下脂肪衰减指数:①肝实质衰减(CTLP);②肝与脾的衰减率(LS率);③肝衰减与脾衰减的不同(LSdif).腹部脂肪分为:全部脂肪(Total fat,TF)、内脏脂肪(Visceral fat,VF)和皮下脂肪(Subcuta-neous fat,SF).使用bivariate相关法评估3个脂肪衰减指数与TF、VF和SF的关系.结果 CTLP、LS率和LSdif与TF、VF和SF分别呈显著负相关.CTLP与TF、VF存在明显负相关(r值分别为-0.415和-0.434,P<0.001).CTLP与SF之间有较小的负相关性(r=-0.313,P<0.001).结论 肝脂肪浸润与腹部脂肪的量关系密切,并且内脏脂肪与脂肪肝存在负相关性.

目的 探讨索拉非尼对中晚期肝癌介入治疗患者生存率及不良反应的影响.方法 按照随机数字表法将80例中晚期肝癌介入治疗患者均分为实验组和对照组.对照组行介入治疗,实验组在此基础上加用索拉非尼,对比2组患者临床疗效、临床症状改善情况、不良反应以及生存情况.结果 2组患者临床疗效对比,差异无统计学意义(P＞0.05).实验组患者食欲减退和肝区疼痛改善率均显著优于对照组,差异具有统计学意义(P＜0.05);实验组患者高血压、手足综合征及腹泻发生率显著高于对照组,差异具有统计学意义(P＜0.05).实验组患者6个月、12个月、24个月生存率以及中位无进展生存期均显著高于对照组,差异具有统计学意义(P＜0.05).结论 索拉非尼可延长中晚期肝癌介入治疗患者生存时间,改善临床症状,但会明显增加不良反应,临床用药需谨慎.

Percutaneous ethanol injection is an important localized treatment method for patients presenting with hepatocellular carcinoma (HCC). Among the advantages of percutaneous ethanol injection are its minimal invasiveness, simplicity, low cost and low risk of complications. However, the increasing popularity of percutaneous ethanol injection has resulted in serious adverse effects attributed to individual variations. The present study describes the case of a patient who exhibited acquired amegakaryocytic thrombocytopenic purpura, caused by percutaneous ethanol injection treatment for HCC. This complication was promptly identified, and platelet transfusion and injection of recombinant human interleukin-11 resulted in a rapid recovery of the patient's platelet count. Attention should be given to this rare complication in patients administered percutaneous ethanol injection treatment for HCC.

Hepatocellular carcinoma (HCC) originating from the caudate lobe is a special-site HCC, which is rare and difficult to treat. The major therapeutic method in the past was surgical resection. In recent years, interventional treatment for HCC originating from the caudate lobe has achieved significant progress, and good therapeutic effect has been obtained. This paper briefly introduces the anatomic features of the caudate lobe and the features of blood supply in HCC originating from the caudate lobe, reviews the research advances in the therapeutic methods of transcatheter arterial chemoembolization and local ablation for HCC originating from the caudate lobe, and points out that a combination of interventional therapies for HCC originating from the caudate lobe needs to be further investigated in clinical practice.

ObjectiveTo compare the effectiveness of stereotactic body radiotherapy (SBRT) and radiofrequency ablation (RFA) for hepatocellular carcinoma.MethodsFrom Jan 2011 to Dec 2012, 77 patients with inoperable single hepatocellular carcinoma 5cm or smaller underwent SBRT (n=37) or RFA (n=40).ResultsThe follow-up period was 3~58 months. In SBRT group, complete response (CR) was attained in 19 cases (51.35%),partial response (PR) was attained in 13 cases (35.13%),stable disease(SD) was attained in 4 cases (10.81%), progression disease (PD) was attained in one case (2.71%), the response rate(CR+PR) was 86.48%. In RFA group,CR was attained in 23 cases (57.50%), PR was attained in 13 cases (32.50%), SD was attained in 1 case (2.50%), PD was attained in three cases (7.50%) , and the response rate was 90.00%. There weren’t significant differences between two groups(P>0.0). Overall survival rate (OS) ,1, 2 and 3 years after treatment were 94.59%, 81.08% and 70.27% after SBRT and 97.50%, 87.50% and 82.50% after RFA, there weren’t significant difference between two groups (P=0.209). Local control (LC) rate 1, 2 and 3 years after treatment were 94.59%, 91.89% and 89.19% after SBRT and 90.00%, 85.00% and 82.50% after RFA, there weren’t significant difference between two groups(P=0.394).ConclusionsBoth SBRT and RFA are effective local treatment options for inoperable hepatocellular carcinoma (single, diameter less than 5 cm). SBRT should be considered as an alternative treatment for patients with hepatocellular carcinoma which is unsuitable for surgical treatment.

The purpose of the present study was to characterize uncommon portosystemic collateral circulation in hepatic cirrhosis. Portosystemic uncommon collateral circulation (UCC) was detected, characterized and evaluated by a combination of spiral computed tomography angiography, three-dimensional imaging angiography and electronic gastroscopy in patients diagnosed with hepatic cirrhosis. In total, 118 cases with UCC were detected from a pool of 700 hepatic cirrhosis patients with portal hypertension. The incidence was 16.86% and included cases with splenic-renal, gastro-renal, paravertebral, retroperitoneal, gastric-splenic and cardio-phrenic angle vein shunts. The occurrence rate of UCC formation increased with the Child-Pugh grade. Compared with common collateral circulations, the incidence of severe esophageal or gastric fundus varicose veins, severe portal hypertensive gastropathy and the incidence of a large quantity of ascites was much lower in the patients with UCC (P<0.01), whereas the incidence of hepatic encephalopathy and chronic elevated blood ammonia levels was significantly higher (P<0.01). The incidence of uncommon portosystemic collateral circulation is extremely common in patients with liver cirrhosis and is associated with the Child-Pugh grades of hepatic function. UCC can aid in the relief of the complications derived from portal hypertension, but it may increase the incidence of hepatic encephalopathy and chronic elevated blood ammonia levels.

患者女，59岁。因“间断右季肋部胀痛不适伴发热1个月”于2009年8月4日入院。患者自2009年7月初无明显诱因间断出现右季肋部胀痛不适伴发热，同时伴有咳嗽、咳痰、纳差、乏力等。2009年7月27日再次出现上述症状，当地医院怀疑肝脓肿可能性大。为求进一步诊治转入我院。入院查体：全腹软，未触及包块，肝右肋下、剑突下未触及，肝区轻度叩痛，双下肢轻度凹陷性水肿。肝功能检查：ALT 40 U／L，AST 50 U／L，白蛋白23 g／L，球蛋白26 g／L，总胆红素13．3μmol／L，直接胆红素6．6μmol／L，胆碱酯酶2352 U／L。肿瘤标记物：CA12511．60 U／mL，CA19939．64 U／mL，CEA 0．27 ng／mL，CA72－42．23 U／mL。腹部CT检查：肝内多发低密度团块影，边界清晰。 MRI检查：肝内多发肿块伴肝实质肿胀，腹腔及腹膜后未见肿大淋巴结。入院诊断：肝脓肿？肝肿瘤？2009年8月10日行剖腹探查术、肝脓肿切开引流术。手术探查可见腹腔少量腹水，胆囊床和大网膜粘连；肝右叶内脓肿，未突出肝表面，触之质稍软；肝左叶Ⅱ段、部分Ⅲ段类似脓肿样肿物突出肝表面，触之质软。肝左叶脓肿样肿物切开，见鱼肉坏死样组织，清除鱼肉坏死样组织约15 mL，冰冻病理检查结果为肝肉瘤待排除。肝右叶脓肿切开，清除鱼肉坏死样组织约50 mL。术后病理回报：肝脏原发性淋巴瘤（ PHL ），成熟B细胞来源，小B淋巴细胞；免疫组化：CD20多数细胞阳性，CD3／CD8少数细胞阳性， CK19胆管阳性， CK10阴性， Ki67增值指数＞80％， NSE阴性， S－100阴性， CD34血管阳性。告知患者及家属需专科化疗，患者放弃治疗，自动出院。

目的 对比分析明胶海绵颗粒及Embosphere微球栓塞肝癌破裂出血靶血管的安全性和临床疗效.方法 采用经导管肝动脉栓塞术(TAE),对422例破裂出血的肝癌患者行肝癌出血靶动脉栓塞止血,其中198例采用明胶海绵颗粒栓塞(明胶海绵组),224例采用Embosphere栓塞微球栓塞(微球组),术后结合生化及影像学检查观察和分析临床疗效与不良反应.结果 本组422例均有效止血.明胶海绵组中,34例栓塞术后24～36 h有复发出血,122例肝转氨酶有不同程度升高(31例转氨酶升至1000 U/L以上),198例胆红素均有不同程度上升;微球组中,术后肝功能指标与术前比较差异无统计学意义.结论 与明胶海绵栓塞剂比较,Embosphere栓塞微球颗粒治疗肝癌破裂出血具有很好的疗效及安全性,不良反应轻,再通出血概率低,对术后肝功能的损害甚微,有利于围术期患者的良性恢复,值得在临床上推广应用.