個案報道：三維適形消融治療肝左葉膽管細胞癌1例

扈彩霞 鄭加生 孫斌

·病例報告·

個案報道：三維適形消融治療肝左葉膽管細胞癌1例

扈彩霞 鄭加生 孫斌

肝細胞癌和膽管細胞癌是常見的兩種肝臟腫瘤。不能切除的未經(jīng)治療的膽管細胞癌患者預后差，尤其是發(fā)生門靜脈受侵的患者。目前膽管細胞癌尚無有效的治療手段。射頻消融（radiofrequency ablation， RFA)在不能進行手術(shù)切除的肝惡性腫瘤治療中發(fā)揮重要作用，在此，我們報道成功運用射頻消融治療伴有門靜脈癌栓的肝內(nèi)膽管細胞癌一例，該患者共計存活26個月。

肝內(nèi)膽管細胞癌，腫瘤栓子，射頻消融

病例介紹

肝細胞癌和膽管細胞癌是常見的兩種肝臟腫瘤。不能切除的未經(jīng)治療的膽管細胞癌患者預后差，尤其是發(fā)生門靜脈受侵的患者，中位生存時間約為3個月[1]。主要死亡原因為疾病進展所致肝功能惡化、膽管炎和敗血癥，以及反復發(fā)作的膽道梗阻[2]。這些病人中大部分患者因為慢性肝病基礎(chǔ)所致肝儲備能力差或者肝內(nèi)有多發(fā)病灶，故僅有少數(shù)患者能夠進行手術(shù)切除。射頻消融（radiofrequency ablation，RFA)在不能進行手術(shù)切除的肝惡性腫瘤治療中發(fā)揮重要作用，在此，我們報道成功運用射頻消融治療伴有門靜脈癌栓的肝內(nèi)膽管細胞癌一例。

患者，女性，56歲，主因上腹不適伴有乏力15天入院。體格檢查未見明顯腹痛，既往有高血壓病史，口服降壓藥，血壓控制可。無腫瘤家族史?；灆z查：谷丙轉(zhuǎn)氨酶(ALT) 45.8U/L，谷草轉(zhuǎn)氨酶(AST) 34.5U/L，總膽紅素12.9umol/L，堿性磷酸酶（ALP）106.2U/L，CA19-9明顯升高，到392.59U/mL (正常值＜37 U/mL)，其余抽血化驗均正常。乙肝五項表面抗原、核心抗體陰性，丙型肝炎抗體陰性。腹部CT提示肝左葉病變，伴有門靜脈受侵（圖1）。肝占位穿刺活檢病理結(jié)果為肝內(nèi)膽管細胞癌，CK19,CD34,P53和CK8/18陽性表達（圖2,3）。對其施行局部麻醉CT引導下射頻消融治療。

使用Celon三針對其進行消融。條件分別是：140千焦，34分鐘；123千焦38分鐘；120千焦30分鐘；130千焦35分鐘；131千焦35分鐘，92千焦28分鐘（圖4）。射頻消融結(jié)束后，行即時CT檢查，了解有無出血、腹水等并發(fā)癥發(fā)生。術(shù)后7天行腹部CT檢查評價治療效果。如果在消融區(qū)域發(fā)現(xiàn)殘余病灶，進行再次消融治療。該患者3個月內(nèi)進行4次消融。最后患者獲得完全消融，病灶周邊有0.5-1cm消融邊緣。最后患者整個左葉完全消融（圖5）。

Figure 1．Contrast-enhanced CT images of 56-year-old woman with intrahepatic cholangiocarcinoma. It revealed left lobe of liver's lesions and left branch of portal vein was invasive.

Figure 2．Original magnif i cations, ×200 and ×400,A,B. Hematoxylin and eosin staining showed morphologic evaluation of intrahepatic cholangiocarcinoma obtained from the patient.

Figure 3．Immunohistochemistry for Hepatocyte(C) and CK-19 (D)in the patient.Hepatocyte staining showed that cancer cells were generally negative. A diffusely positive staining was observed in the tumoral cells for CK-19.

Figure 4．CT guided percutaneous RFA. RFA of the tumor thrombus in the left portal vein and the whole left lobe of liver.

Figure 5．Follow up contrast-enhanced CT images after 6 months from the last time of RFA.The patient's left lobe of liver was ablated completely

討論

膽管癌是原發(fā)性肝腫瘤中第二常見腫瘤，發(fā)生率高[3-5]。其惡性程度高，各種治療效果差。膽管癌發(fā)生于膽管上皮細胞，沿著膽管可發(fā)生于任何部位。可分為肝內(nèi)膽管細胞癌和肝外膽管細胞癌[6]。肝內(nèi)膽管癌（ICC）的全球發(fā)病率在最近幾十年來增加了2–6%。肝內(nèi)膽管細胞癌因缺乏特異性癥狀，在診斷時多已發(fā)展至晚期，總體預后比肝外膽管細胞癌差[7-9]。ICC的診斷仍然是特別具有挑戰(zhàn)性。目前唯一有效的治療方法是手術(shù)。不幸的是，大多數(shù)患者在診斷時，疾病已經(jīng)發(fā)展至晚期，失去手術(shù)切除機會[10-12]。大部分患者因為慢性肝病基礎(chǔ)所致肝儲備能力差或者肝內(nèi)有多發(fā)病灶，故僅有少數(shù)患者能夠進行手術(shù)切除[13]。并且，其對化療也不敏感，大多數(shù)為乏血供腫瘤。肝動脈導管化療栓塞（Transarterial chemoembolization，TACE）是通過增加病灶局部化療藥濃度來殺滅腫瘤細胞，從而減少化療的全身副作用，故其對ICC的療效很差。不管腫瘤血管分布怎樣，經(jīng)皮射頻消融（RFA）對于不能手術(shù)切除的腫瘤患者是安全和有效的[14-17]。

在本病例中，患者門靜脈左支受侵。CT引導下RFA治療門靜脈癌栓未見報道。在這例病例報告，我們成功完成了ICC合并門靜脈癌栓的肝左葉完全消融。眾所周知，肝癌患者合并有門靜脈癌栓這預后極差，因為腫瘤生長迅速，常常伴有病灶肝內(nèi)轉(zhuǎn)移、肝功能惡化以及門脈高壓所致上消化道出血等嚴重并發(fā)癥。Fujii等[18]報道，合并門靜脈癌栓患者，不管癌栓是在門脈左支、右支或主干，1年生存率為20.9%，2年生存率為6.2%。在本病例中，患者通過RFA聯(lián)合TACE治療，防止門靜脈癌栓蔓延至主干，延長患者患者的生存期為26個月。其主要并發(fā)癥為消融術(shù)后6個月發(fā)生肝內(nèi)膽汁瘤，經(jīng)過經(jīng)皮膽汁瘤引流緩解癥狀。總之，RFA在一些不能手術(shù)切除的病例中可以成功控制局部腫瘤發(fā)展，在肝腫瘤的治療中發(fā)揮重要作用。

1 Park J, Kim MH, Kim KP, et al. Natural history and prognostic factors of advanced cholangiocarcinoma without surgery, chemotherapy, or radiotherapy: a large-scale observational study. Gut Liver 2009;3 :298-305

2 Burger I, Hong K, Schulick R, et al. Transcatheter arterial chemoembolization in unresectable cholangiocarcinoma: initial experience in a single institution. J Vasc Interv Radiol2005 ;16 :353-361

3 Patel T. Increasing incidence and mortality of primary intrahepatic cholangiocarcinoma in the United States. Hepatology. 2001;33:1353-1357.

4 Taylor-Robinson SD, Toledano MB, Arora S, et al. Increase in mortality rates from intrahepatic cholangiocarcinoma in England and Wales, 1968-1998. Gut. 2001;48:816-820.

5 Davila JA, El-Serag HB. Cholangiocarcinoma: the “other“ liver cancer on the rise. Am J Gastroenterol. 2002;97:3199-3200.

6 de Groen PC, Gores GJ, LaRusso NF, et al. Biliary tract cancers. N Engl J Med. 1999;341:1368-1378.

7 Park J, Kim MH, Kim KP, et al. Natural history and prognostic factors of advanced cholangiocarcinoma without surgery, chemotherapy, or radiotherapy: a large-scale observational study. Gut Liver 2009;3 :298-305

8 Burger I, Hong K, Schulick R, et al. Transcatheter arterial chemoembolization in unresectable cholangiocarcinoma: initial experience in a single institution. J Vasc Interv Radiol2005 ;16 :353-361

9 Nakeeb A, Tran KQ, Black MJ, et al. Improved survival in resected biliary malignancies. Surgery 2002;132 :555-563

10 Ben-Menachem T. Risk factors for cholangiocarcinoma. Eur. J. Gastroenterol. Hepatol.2007, 19, 615–617

11 Blechacz B. R., Gores G. J.Cholangiocarcinoma. Clin. Liver Dis. 2008,12, 131–150,

12 El-Serag H. B., Engels E. A., Landgren O., Chiao E., Henderson L., Amaratunge H. C., Giordano T. P.Risk of hepatobiliary and pancreatic cancers after hepatitis C virus infection: a population-based study of U.S. veterans. Hepatology,2009, 49, 116–123

13 Aljiffry M, Walsh MJ, Molinari M. Advances in diagnosis, treatment and palliation of cholangiocarcinoma: 1990–2009. World J Gastroenterol 2009;15 :4240-4262

14 De Baere T, Deschamps F, Briggs P, et al. Hepatic malignancies: percutaneous radiofrequency ablation during percutaneous portal or hepatic vein occlusion. Radiology 2008;248 :1056-1066

15 Cho YK, Kim JK, Kim MY, Rhim H, Han JK. Systematic review of randomized trials for hepatocellular carcinoma treated with percutaneous ablation therapies. Hepatology 2009;49 :453-459

16 Stang A, Fischbach R, Teichmann W, Bokemeyer C, Braumann D. A systematic review on the clinical benef i t and role of radiofrequency ablation as treatment of colorectal liver metastases. Eur J Cancer 2009;45 :1748-1756

17 Meloni MF, Andreano A, Laeseke PF, Livraghi T, Sironi S, Lee FT Jr. Breast cancer liver metastases: US-guided percutaneous radiofrequency ablation—intermediate and long-term survival rates. Radiology 2009;253 :861-869

18 Fujii T, Takayasu K, Muramatsu Y, Moriyama N, Wakao F, Kosuge T, et al. Hepatocellular carcinoma with portal tumor thrombus: analysis of factors determining prognosis. Jpn J Clin Oncol 1993;23:105–9.

3-Dimension Conformal Technology Guided Radiofrequency Ablation of liver's left lobe for Intrahepatic Cholangiocarcinoma: A Case Report

Jiasheng Zheng,Caixia Hu, Bin Sun
Center of Minimally Invasive Intervention, Beijing You-an Hospital, Capital Medical University, Beijing 100069, P.R.China

Dr Jiasheng Zheng, Center of Minimally Invasive Intervention, Beijing You-an Hospital, Capital Medical University, Beijing 100069, P.R.China ;

Hepatocellular carcinoma and cholangiocarcinoma are the two most common malignant liver tumors.The prognosis for patients with untreated unresectable cholangiocarcinoma is depressed,especially to the patient with invasion in the portal vein. It has no effective treatment presently. Radiofrequency ablation (RFA) plays an importmant role in the treatment of unresectable liver tumors.It is considered a viable alternative to surgery for inoperable patients. Here,we report the successful use of CT- guided RFA in a patient with intrahepatic Cholangiocarcinoma with invasion in the portal vein.The patient survived for 26 months.

intrahepatic cholangiocarcinoma, tumor thrombus, radiofrequency ablation

2013-06-05）

（本文編輯：黃強）

10.3877/cma.j.issn.2095-5782.2014.03.018

100069 首都醫(yī)科大學附屬北京佑安醫(yī)院介入中心

鄭加生，Email: jiashengzheng@yahoo.com;