Multidisciplinary comprehensive treatment of postoperative recurrence of hepatocellular carcinom / 中国实用外科杂志

The treatment modality of recurrent hepatocellular carcinoma(HCC) includes surgical resection, liver transplantation, ablation, interventional therapy, targeted therapy,and systemic chemotherapy. However,the complexity of disease condition often leads to unsatisfying outcome by single treatment, making multidisciplinary treatment an inevitable choice. Commonly used combined therapies are transarterial chemoembolization(TACE) combined with surgical resection,TACE combined with local ablation,and TACE combined with systemic treatment. In clinical practice,the goal of comprehensive treatment is prolonged survival and improved quality of life. Choosing different combination of therapies according to different liver function,general condition and recurrence of tumors can significantly improve the patients' survival.

Intravascular Ultrasound Classification of Plaque in Angiographic True Bifurcation Lesions of the Left Main Coronary Artery / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Accurately, characterizing plaques is critical for selecting the optimal intervention strategy for the left main coronary artery (LMCA) bifurcation. Coronary angiography cannot precisely assess the location or nature of plaques in bifurcation lesions. Few intravascular ultrasound (IVUS) classification scheme has been reported for angiographic imaging of true bifurcation lesions of the unprotected LMCA thus far. In addition, the plaque composition at the bifurcation has not been elucidated. This study aimed to detect plaque composition at LMCA bifurcation lesions by IVUS.</p><p><b>METHODS</b>Fifty-eight patients were recruited. The location, concentricity or eccentricity, site of maximum thickness, and composition of plaques of the distal LMCA, ostial left anterior descending (LAD) coronary artery and, left circumflex (LCX) coronary artery were assessed using IVUS and described using illustrative diagrams.</p><p><b>RESULTS</b>True bifurcation lesions of the unprotected LMCA were classified into four types: Type A, with continuous involvement from the distal LMCA to the ostial LAD and the ostial LCX with eccentric plaques; Type B, with concentric plaques at the distal LMCA, eccentric plaques at the ostial LAD, and no plaques at the LCX; Type C, with continuous involvement from the distal LMCA to the ostial LCX, with eccentric plaques, and to the ostial LAD, with eccentric plaques; and Type D, with continuous involvement from the distal LMCA to the ostial LAD, with eccentric plaques, and to the ostial LCX, with concentric plaques. The carina was involved in only 3.5% of the plaques. A total of 51.7% of the plaques at the ostium of the LAD were soft, while 44.8% and 44.6% were fibrous in the distal LMCA and in the ostial LCX, respectively.</p><p><b>CONCLUSIONS</b>We classified LMCA true bifurcation lesions into four types. The carina was always free from disease. Plaques at the ostial LAD tended to be soft, whereas those at the ostial LCX and the distal LMCA tended to be fibrous.</p>

Clinical impact of dual antiplatelet therapy use in patients following everolimus-eluting stent implantation: insights from the SEEDS study / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Studies have suggested that use of prolonged dual antiplatelet therapy (DAPT) following new generation drug-eluting stent implantation may increase costs and potential bleeding events. This study aimed to investigate the association of DAPT status with clinical safety in patients undergoing everolimus-eluting stent (EES) implantation in the SEEDS study (A Registry to Evaluate Safety and Effectiveness of Everolimus Drug-eluting Stent for Coronary Revascularization) at 2-year follow-up.</p><p><b>METHODS</b>The SEEDS study is a prospective, multicenter study, where patients (n = 1900) with small vessel, long lesion, or multi-vessel diseases underwent EES implantation. Detailed DAPT status was collected at baseline, 6-month, 1- and 2-year. DAPT interruption was defined as any interruption of aspirin and/or clopidogrel more than 14 days. The net adverse clinical events (NACE, a composite endpoint of all-cause death, all myocardial infarction (MI), stroke, definite/probable stent thrombosis (ST), and major bleeding (Bleeding Academic Research Consortium II-V)) were investigated according to the DAPT status at 2-year follow-up.</p><p><b>RESULTS</b>DAPT was used in 97.8% of patients at 6 months, 69.5% at 12 months and 35.4% at 2 years. It was observed that the incidence of NACE was low (8.1%) at 2 years follow-up, especially its components of all-cause death (0.9%), stroke (1.1%), and definite/probable ST (0.7%). DAPT was not an independent predictor of composite endpoint of all-cause death/MI/stroke (hazard ratio [HR]: 0.693, 95% confidence interval [CI]: 0.096-4.980, P = 0.715) and NACE (HR: 1.041, 95% CI: 0.145-7.454, P = 0.968). Of 73 patients who had DAPT interruption, no patient had ST at 12-month, and only 1 patient experienced ST between 1- and 2-year (1.4%). There was a high frequency of major bleeding events (53/65, 82.5%) occurred in patients receiving DAPT treatment.</p><p><b>CONCLUSIONS</b>Prolonged DAPT use was not associated with improved clinical safety. The study emphasized that duration of DAPT needs to be shortened in Chinese patients following EES implantation (ClinicalTrials.gov identifier: NCT 01157455).</p>

Impact of oral anti-hepatitis B therapy on the survival of patients with hepatocellular carcinoma initially treated with chemoembolization / 癌症

<p><b>INTRODUCTION</b>Most hepatocellular carcinomas (HCC) develop in a background of underlying liver disease including chronic hepatitis B. However, the effect of antiviral therapy on the long-term outcome of patients with hepatitis B virus (HBV)-related HCC treated with chemoembolization is unclear. This study aimed to evaluate the survival benefits of anti-HBV therapy after chemoembolization for patients with HBV-related HCC.</p><p><b>METHODS</b>A total of 224 HCC patients who successfully underwent chemoembolization were identified, and their survival and other relevant clinical data were reviewed. Kaplan-Meier and Cox regression analyses were performed to validate possible effects of antiviral treatment on overall survival (OS).</p><p><b>RESULTS</b>The median survival time (MST) was 15.9 (95% confidence interval [CI], 9.5-27.7) months in the antiviral group and 9.6 (95% CI, 7.8-13.7) months in the non-antiviral group (log-rank test, P = 0.044). Cox multivariate analysis revealed that antiviral treatment was a prognostic factor for OS (P = 0.008). Additionally, a further analysis was based on the stratification of the TNM tumor stages. In the subgroup of early stages, MST was significantly longer in the antiviral-treatment group than in the non-antiviral group (61.8 months [95% CI, 34.8 months to beyond the follow-up period] versus 26.2 [95% CI, 14.5-37.7] months, P = 0.012). Multivariate analysis identified antiviral treatment as a prognostic factor for OS in the early-stage subgroup (P = 0.006). However, in the subgroup of advanced stages, MST of the antiviral-treated group was comparable to that of the non-antiviral group (8.4 [95% CI, 5.2-13.5] months versus 7.4 [95% CI, 5.9-9.3] months, P = 0.219). Multivariate analysis did not indicate that antiviral treatment was a significant prognostic factor in this subgroup.</p><p><b>CONCLUSION</b>Antiviral treatment is associated with prolonged OS time after chemoembolization for HCC, especially in patients with early-stage tumors.</p>

Long-term survival of patients with hepatocellular carcinoma with inferior vena cava tumor thrombus treated with sorafenib combined with transarterial chemoembolization: report of two cases and literature review / 癌症

The prognosis of hepatocellular carcinoma (HCC) with tumor thrombus formation in the main vasculature is extremely poor. Sorafenib combined with transarterial chemoembolization is a novel treatment approach for advanced HCC. In this study, we report two HCC patients with inferior vena cava tumor thrombus who underwent the combination treatment. The overall survival times for these two patients were 44 months and 35 months, respectively. Our report suggests that sorafenib combined with transarterial chemoembolization may be a viable choice for patients with advanced HCC even with inferior vena cava tumor thrombus. Further studies are required to verify the efficacy and safety of this combination therapy for patients with advanced HCC with inferior vena cava tumor thrombus.

Three hours continuous injection of adenosine improved left ventricular function and infarct size in patients with ST-segment elevation myocardial infarction / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>The definitive treatment for myocardial ischemia is reperfusion. However, reperfusion injury has the potential to cause additional reversible and irreversible damage to the myocardium. One likely candidate for a cardioprotection is adenosine. The present study aimed at investigating the effect of intravenous adenosine on clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).</p><p><b>METHODS</b>Patients with STEMI within 12 hours from the onset of symptoms were randomized by 1:1:1 ratio to receive either adenosine 50 µg×kg(-1)×min(-1) (low-dose group, n = 31), or 70 µg×kg(-1)×min(-1) (high-dose group, n = 32), or saline 1 ml/min (control group, n = 27) for three hours. Drugs were given to the patients immediately after the guide wire crossed the culprit lesion. Recurrence of no-reflow, TIMI flow grade (TFG) and TIMI myocardial perfusion grade (TMPG), and collateral circulation were recorded. The postoperative and preoperative ST segment elevation sum of 18-lead electrocardiogram (ECG) and their ratio (STsum-post/STsum-pre) were recorded, as well as the peak time and peak value of CK-MB enzyme. Serial cardiac echo and myocardial perfusion imaging were performed at 24 hours and 6 months post-stenting. The primary endpoint was left ventricular function, and infarct size. The secondary end-point was the occurrence of cardiac and non-cardiac death, non-fatal myocardial infarction, and heart failure.</p><p><b>RESULTS</b>A total of 90 STEMI patients were studied. No-reflow immediately after stent procedure was seen in 11 (35.5%) patients in the control group, significantly different from 6.3% in the low-dose group or 3.7% in the high-dose group (both P = 0.001). STsum-post/STsum-pre in the low-dose and high-dose groups was significantly different from the control group (low-dose group vs. control group, P = 0.003 and high-dose group vs. control group, P = 0.001), without a dose-dependent pattern (P = 0.238). The peak value of CK-MB enzyme was significantly reduced in the high-dose group compared to the control group (P = 0.024). Compared to the left ventricular ejection fraction (LVEF) in control group, LVEF in the low-dose group increased by 5.8% at 24 hours (P = 0.012) and by 10.9% at 6 months (P = 0.007), LVEF in the high-dose group increased by 9.5% at 24 hours (P = 0.001) and by 10.0% at 6 months (P = 0.001), respectively. Significant reduction of infarct size by 24.2% was detected in the high-dose group vs. low-dose or control groups (P = 0.008). There was no significant difference regarding secondary endpoints at 6 months among the treated groups. Cardiac function by NYHA classification in both the low-dose and the high-dose groups was improved significantly (P = 0.013, P = 0.016).</p><p><b>CONCLUSION</b>Intravenous adenosine administration might significantly reduce the recurrence of no-reflow, with resultant improved left ventricular systolic function. High-dose adenosine was further associated with significant reduction of infarct size.</p>

Efficacy of combining temperature- and power-controlled radiofrequency ablation for malignant liver tumors / 癌症

<p><b>BACKGROUND AND OBJECTIVE</b>Single mode of radiofrequency ablation (RFA) often leads to limited ablation in the zone of necrosis. This study clarifies the efficacy of combining temperature- and power-controlled RFA for malignant liver tumors.</p><p><b>METHODS</b>Between April 2008 and August 2008, 58 patients with malignant liver tumors received RFA at Sun Yat-sen University Cancer Center. The patients were divided into 2 groups using a random number table: one group received combined temperature- and power-controlled RFA (the combination group), and the other group received power-controlled RFA alone (the control group).</p><p><b>RESULTS</b>Three patients were lost to follow-up and 55 patients were included for evaluation. Twenty-five patients with 29 tumors were treated by the combination RFA, and 27 tumors (93.1%) achieved either complete response (CR) or partial response (PR). One patient had a seriously decreased heart rate. In the control group, 30 patients with 32 tumors received power-controlled RFA, and 29 tumors (90.6%) achieved CR or PR. There were no serious complications. There was no difference between the combination and control groups in treatment time ((13.3 +/- 1.3) min vs. (10.2 +/- 2.3) min, P = 0.459). The number of sessions of RFA for the combination group was less than that of control group (1.3 sessions vs. 2.4 sessions), but the difference was not significant (P = 0.579).</p><p><b>CONCLUSION</b>RFA controlling both temperature and power is effective and safe for patients with malignant liver tumors, and the number of sessions of RFA for the combination group was less than that of the control group.</p>

Percutaneous radiofrequency ablation combined with other minimally invasive treatments for recurrent hepatocellular carcinoma after hepatectomy / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate the efficacy and safety of percutaneous radiofrequency ablation (PRFA) and combined with other minimally invasive treatments for recurrent hepatocellular carcinoma (RHCC) after hepatectomy.</p><p><b>METHODS</b>Eighty-four patients with RHCC after hepatectomy who were treated with PRFA or combined with other minimally invasive therapies between August 1999 and February 2008 were analyzed retrospectively.</p><p><b>RESULTS</b>There was no treatment related mortality in the study population, and the morbidity was 2.4% (2/84). The complete ablation rate was 94.0% (79/84), and the 1-, 3- and 5-year overall survival rates were 74.9%, 54.9% and 48.2%, respectively. The 1-, 3- and 5-year overall survival rates of patients with recurrent interval after hepatectomy less than 1 year and over 1 year were 72.1%, 36.2%, 24.2% and 76.8%, 70.6% and 65.1%, respectively (P = 0.040). The 1-, 3- and 5-year overall survival rates of patients with tumor size <or= 3 cm and > 3 cm were 83.2%, 67.7%, 67.7% and 59.1%, 24.2%, 12.1%, respectively (P = 0.003). The 1-, 3- and 5-year overall survival rates of patients treated with PRFA alone and combined with percutaneous ethanol injection (PEI) were 66.7%, 33.3%, 22.2% and 76.5%, 57.3%, 57.3%, respectively (P = 0.017). The 1-, 3- and 5-year overall survival rates of patients treated with PRFA alone and combined with transcatheter hepatic arterial chemoembolization (TACE) were 55.6%, 24.7%, 24.7% and 81.6%, 66.0%, 57.5%, respectively (P = 0.001).</p><p><b>CONCLUSIONS</b>PRFA is an effective and safe treatment for RHCC, and tumor size and recurrent interval after hepatectomy are important prognostic factors. Combination with PEI or TACE may improve the efficacy of PRFA for treatment of RHCC.</p>

Experience of radiofrequency ablation on liver malignancies: a report of 803 cases / 中华外科杂志

<p><b>OBJECTIVE</b>To summarize the 8-year experience of radiofrequency ablation (RFA) on liver malignancies and explore the effect and prognostic factors.</p><p><b>METHODS</b>From August 1999 to February 2007, 803 patients with liver malignancies, among which there were 672 with primary liver cancer (PLC) and 131 with liver metastasis, were treated with RFA. There were 781 cases who were performed percutaneously under the guidance of ultrasound, 8 cases under CT, 9 cases with laparoscopy and 5 cases with laparotomy. And there were 117 cases who were treated by RFA combined with percutaneous ethanol injection and 108 cases by RFA combined with trans-catheter arterial chemoembolization.</p><p><b>RESULTS</b>In the treatment of all the 803 patients with liver malignancies, the mortality was 0.25%, the rate of severe complications was 0.37%. The rate of complete ablation was 92.5%, the loco-recurrence rate was 13.8% and the 1, 2, 3, 4, 5-year survivals were 95.1%, 85.6%, 75.7%, 60.7% and 47.5%, respectively. For the 672 patients with PLCs, the 1, 2, 3, 4, 5-year survivals with stage Ia (Chinese staging system) were 97.8%, 91.5%, 84.6%, 77.1% and 61.9%, respectively, with stage Ib were 93.9%, 83.7%, 69.8%, 45.1% and 42.2%, respectively, with stage II were 86.2%, 67.3%, 47.3%, 17.2% and 0, respectively, and the 1, 2-year survivals with stage III were 67.8% and 0, respectively (P < 0.01).</p><p><b>CONCLUSIONS</b>RFA is a safe and effective method for liver malignancy, and the tumor size and stage are important prognostic factors.</p>

Observation of the effect of early fluid resuscitation on hepatic fatty degeneration in rats after severe scald / 中华烧伤杂志

<p><b>OBJECTIVE</b>To investigate the efficacy of early fluid resuscitation on hepatic steatosis in rats after severe scald.</p><p><b>METHODS</b>One hundred and forty-four Sprague-Dawley rats were enrolled in the study. In thirty-six rats skin of 30% TBSA was treated with cold water to serve as sham injury group. All other rats were inflicted with 30% full-thickness scald, and they were subdivided into 3 groups, i. e. scald group(S, without resuscitation), delayed resuscitation group ( DR, with Ringer's solution at 6 post-scald hour(PSH) ) and early resuscitation group( ER, with Ringer's solution immediately after scald). The hepatic tissues of the rats were harvested at 0.5, 1.0,2.0,3.0,7.0 post-scald hour( PSH) and on 21.0 PSD for the observation of pathological changes with light-microscope and transmission electron microscope. The serum contents of TC, TG, HDL, ALP were determined at the same time-points. Body weight of each rat was measured before blood sampling, and total liver weight after blood sampling. Liver weight/body weight ratio was recorded.</p><p><b>RESULTS</b>Compared with sham injury group, the fat denaturation degree of hepatic tissue in ER group was obviously less than that in S and DR group . The serum level of high density lipoprotein (TC) , triglyceride ( TG) , and alkaline phosphatase (ALP) after scald increased ranking as S > DR > ER, while the level of HDL decreased in that order. The liver weight/body weight ratio of the rats in DR group on 1.0 PSD was obviously elevated compared with that in ER group( P <0. 05) , and there exhibited significant difference of liver weight/body weight ratio between DR and ER groups on 7. 0 PSD ( P < 0. 01). The liver steatosis had obvious negative correlation with HDL content after scald( r = -0. 37, P <0.01) , but it had positive correlation with the ALP content( r = 0. 45, P <0. 01), TG content( r = 0. 25, P <0. 01) and liver weight/body weight ratio( r = 0. 440, P <0. 01). The remaining parameters showed no correlation with the liver steatosis.</p><p><b>CONCLUSION</b>Fluid resuscitation immediately after scald can ameliorate hepatic fatty degeneration, reduce its incidence, and beneficial to recovery of liver damage to a certain extent.</p>

Randomized clinical trial of percutaneous radiofrequency ablation plus absolute ethanol injection compared with radiofrequency ablation alone for small hepatocellular carcinoma / 中华肿瘤杂志

<p><b>OBJECTIVE</b>To compare percutaneous radiofrequency ablation (RFA) alone and RFA combined with percutaneous absolute ethanol injection (RFA-PEI) in the treatment of single hepatocellular carcinoma smaller than 5.0 cm in diameter.</p><p><b>METHODS</b>From Jan. 2002 till Dec. 2003, eighty-six patients were put on a randomized clinical trial. For RFA, the American Radiotherapeutics RF 2000 machine and 3.5 cm/LEE VEEN + electroradiofrequency needle was introduced under ultra-beta sound guide. For tumor < 3 cm, the needle was left in center of tumor and for tumor > 3 cm, the needle was first left in situ and twisted by 180 as it was withdrawn for every 1 cm, till the surface border was reached. Power output was increased from 20 W and raised by 10-20 W per minute until the impedance became rapidly raised and the output decreased. Forty-five patients were treated with RFA-PEI and 41 with RFA, with each group divided into group A (diameter < or = 3.0 cm) and group B (diameter = 3.1-5.0 cm) according to tumor size. The overall and local recurrence-free survival was used to evaluate the treatment effect.</p><p><b>RESULTS</b>There was no mortality or serious morbidity in either group. The 6-, 12-, 18-, 24-month survival rate of RFA-PEI and RFA was 88.9%, 84.0%, 80.6%, 73.9% and 87.7%, 78.3%, 73.7%, 61.4% (P = 0.6181), respectively; and the local recurrence-free survival rates was 95.4%, 95.4%, 87.8%, 73.7% and 94.9%, 72.7%, 68.4%, 57.1% (P = 0.0393), respectively. The local recurrence-free survival rate in group A was 95.7%, 95.7%, 79.1%, 79.1% and 92.3%, 83.2%, 81.3%, 65.9% (P = 0.3679), respectively; while in group B was 95.0%, 95.0%, 95.0%, 72.6% and 100.0%, 58.3%, 45.4%, 45.4% (P = 0.0440).</p><p><b>CONCLUSION</b>Percutaneous radiofrequency ablation combined with percutaneous absolute ethanol injection is safe, and more effective and easily practiced than percutaneous radiofrequency ablation alone in the treatment of small hepatocellular carcinoma, especially when the tumor is greater than 3 cm in diameter, for which RFA-PEI may be able to reduce local recurrence and improve long-term survival.</p>