肝癌合并门静脉癌栓的临床病理分级及意义

Clinicopathological staging of portal vein tumor thrombosis in hepatocellular carcinoma and its significance l

目的评价肝细胞痈(HCC)合并门静脉癌栓(PVTT)临床病理分型在外科治疗 HCC合并 PVTT 中的意义和价值。方法 42例 HCC 合并 PVTT 病人,按门静脉主干及其一级分支受累情况、以及有无肝外淋巴结转移将 PVTT 分为Ⅴ级:Ⅰ级为门静脉一级分支,即门静脉左或右干(LPV、RPV)有瘤栓;Ⅱ级 LPV 或 RPV 加门静脉主干(TPV)被侵犯;Ⅲ级 LPV、RPV 和 TPV 均受累:Ⅳ级为Ⅲ级加脾静脉或肠系膜上静脉被累及:Ⅴ级为Ⅰ～Ⅳ任何级加肝外组织或淋巴结转移。外科治疗包括肝叶切除加癌栓清除(33例)、门静脉主干切开取栓(9例)等。病理上对30例癌栓行组织学分型,并对其影像学、大体解剖特征和临床经过进行对比分析。结果癌栓分级Ⅰ到Ⅴ级的例数分别为14、12、11、2和3例,术后中位存活时间分别是28、17.5、7、6、6个月。30例 PVTT 病理分型增殖型50%、坏死型36.7%、机化型13.3%。4例机化型癌栓手术无法彻底清除,预后不良。结论本项研究的结果提示:(1)HCC 合并 PVTT 临床病理分型有助于判断预后,Ⅲ级以上病人预后不良,尤其是机化型 PVTT。(2)合理选择外科治疗方法,Ⅰ、Ⅱ级宜外科手术,Ⅲ级合并急性上消化道大出血者,可行主干切开取栓术。其余应以综合治疗为主,一股不宜手术治疗。此外,机化型 PVTT 在Ⅱ级以上不官切除治疗。(3)PVTT 的外科治疗要强调无瘤原则,尽量避免癌栓术中扩散。

Objective To determine the value of clinicopathological staging of portal vein tumor thrombosis （PVTT） for surgical treatment of hepatocellular carcinoma （HCC）. Methods According to the tumor invasion of portal trunk and its first branch as well as extrahepatic metastasis of lymph nodes, PVTT in 42 patients with HCC were divided into 5 stages： stage Ⅰ the first branch of the left or right portal vein was invaded by tumor thrombosis; stage Ⅱ the trunk and first branch of the left or right portal vein were invaded; stage Ⅲ the trunk and first branch of the left and right portal vein were invaded; stage Ⅳ included stage Ⅲ and invasion of superior mesenteric vein or splenic vein; stage Ⅴ included any of the stages Ⅰ -Ⅳ and extrahepatic metastasis of lymph nodes. Surgical treatments included different types of hepatectomy with removal of tumor thrombi in 33 patients and hepatectomy and thrombectomy in the trunk of portal vein in 9. The samples of tumor thrombus from 30 patients were analyzed and contrasted according to image and gross findings as well as clinical courses. Results The numberof patients with HCC of stag Ⅰ to stage Ⅴ was 14, 12, 11, 2 and 3, respectively. Their median postoperative survival time was 28, 17. 5, 7, 6 and 6 months, respectively. There were 3 types of PVTT in the 30 patients. They were proliferative type in 15 （50%）, necrotic one in 11 （36. 7%） and organized one in 4 （13.3%）. In the 4 patients with the organized type, PVTT was difficult to remove and prognosis was worse. Conclusions 1） The clinicopathological staging of PVTT is helpful to predict the prognosis of the patients. The patients with HCC of stage Ⅲ or over or with organized type of PVTT have poorer prognosis. 2） The staging is useful for selecting the reasonable surgical procedures for the patients with PVTT. Better results can be gained in the patients with HCC of stage Ⅰ or Ⅱ. When acute hemorrhage from upper gastrointestinal tract occurs, thrombectomy in the trunk of portal vein can be performed to effectively stop the bleeding. The patients with HCC of stage Ⅱ or over and organized type of PVTT are not good candidates for the surgical treatment. 3） Surgical dissection of the portal vein trunk and its first branches at porta hepatis should be performed to prevent tumor thrombus spreading during the operation.