选择性肝动脉和门静脉阻断、二步肝切除治疗肝癌的安全性和疗效研究

目的探讨二步肝切除(先选择性肝动脉和门静脉阻断,再行肝癌切除)治疗肝癌的安全性和疗效。方法选取2014年12月-2018年4月浙江大学医学院附属杭州市第一人民医院收治的乙型肝炎并原发性肝癌患者7例,平均年龄44.1岁,术前甲胎蛋白(AFP)都高于正常值,平均肿瘤直径13.0 cm。第1步通过手术或介入的方法行选择性肝动脉和门静脉阻断,不进行肝脏实质的离断。术后1~2周内评估预留肝脏体积(FLR)的增生情况,如FLR的增生达到要求则行肝切除手术。2期分别进行右半肝切除、扩大右半肝切除及扩大左半肝切除。结果第1步手术或栓塞后无肝衰竭及死亡的发生。所有患者的FLR在第1步后有不同程度的增生。术前患者平均FLR占标准肝体积的百分比是32.1%,第1步后8~15 d增加到40.5%,满足第2步肝切除的需要。7例患者分别在第一步完成后8~18 d行第2步肝切除,第2步肝切除后无死亡发生。7例患者中有6例甲胎蛋白术后2个月降到正常范围。随访截止时间2018年11月20日,有4例患者仍然存活,并且其中3例是无瘤生存,最长的1例无瘤生存已达35.9个月。结论选择性肝动脉和门静脉阻断、不离断肝脏实质能够促进剩余肝脏体积的增生,在此基础上行巨大肝癌切除术疗效好,易于推广。

The molecular mechanism underlying angiogenesis in hepatocellular carcinoma: the imbalance activation of signaling pathways

OBJECTIVE: To explore the effect of two dominating signaling pathways, VEGF/KDR andangiopoietins/Tie2, on the formation of new blood vessel in hepatocellular carcinoma (HCC) growth andmetastasis.METHODS: RT-PCR and Western blot were employed to evaluate the VEGF/KDR andangiopoietins/Tie2 expression in samples from 23 patients with HCC. Meanwhile, microvessel density(MVD) was determined as a marker of angiogenesis by counting CD34 positive cells with the method ofimmunohistochemistry.RESULTS: The two pathways were activated in all HCC samples. The expressions of vascular endothelialgrowth factor (VEGF) and angiopoietin-2 (Ang2) were significantly higher (P【0.05) in hepatocellularcarcinoma tissues and the margin of the tumor than those in control groups, and so did CD34 positivecells. Although significant difference in the expression of kinase insert domain containing receptor (KDR)and Ang1/Tie2 was not observed in all groups, their distinct high levels were seen in hepatoma and itsmargin compared with normal and cirrhotic liver. VEGF and Ang2 expressions were seen up-regulated inHCC with vascular invasion and satellite lesion.CONCLUSIONS: The two signaling pathways, VEGF/KDR and angiopoietins/Tie2 are activated in theprocess of angiogenesis in HCC and modulate the formation of new blood vessels. The imparity of the twosignaling pathways’ activation is to benefit HCC metastasis. In the two pathways, VEGF and Ang2 mayplay an important role in the process of angiogenesis, and are necessary indicators for the prognosis andmetastasis of HCC. This study provides another clue for the exploration of anti-angiogenic agents.

Hepatectomy with primary closure of common bile duct for hepatolithiasis combined with choledocholithiasis

AIM: To evaluate the feasibility of hepatectomy and primary closure of common bile duct for intrahepatic and extrahepatic calculi. METHODS: From January 2008 to May 2013, anatomic hepatectomy followed by biliary tract exploration without biliary drainage(non-drainage group) was performed in 43 patients with intrahepatic and extrahepatic calculi. After hepatectomy, flexible choledochoscopy was used to extract residual stones and observe the intrahepatic bile duct and common bile duct(CBD) for determination of biliary stricture and dilatation. Function of the sphincter of Oddi was determined by manometry of the CBD. Primary closure of the CBD without T-tube drainage or bilioenteric anastomosis was performed when there was no biliary stricture or sphincter of Oddi dysfunction. Dexamethasone and anisodamine were intravenously injected 2-3 d after surgery to prevent postoperative retrograde infection due to intraoperative bile duct irrigation, and to maintain relaxation of the sphincter of Oddi, respectively. During the same period, anatomic hepatectomy followed by biliary tract exploration with biliary drainage(drainage group) was performed in 48 patients as the control group. Postoperative complications and hospital stay were compared between the two groups.RESULTS: There was no operative mortality in either group of patients. Compared to intrahepatic and extrabiliary drainage, hepatectomy with primary closure of the CBD(non-drainage) did not increase the incidenceof complications, including residual stones, bile leakage, pancreatitis and cholangitis(P > 0.05). Postoperative hospital stay and costs were nevertheless significantly less in the non-drainage group than in the drainage group. The median postoperative hospital stay was shorter in the non-drainage group than in the drainage group(11.2 ± 2.8 d vs 15.4 ± 2.1 d, P = 0.000). The average postoperative cost of treatment was lower in the non-drainage group than in the drainage group(29325.6 ± 5668.2 yuan vs 32933.3 ± 6235.1 yuan, P = 0.005). CONCLUSION: Hepatectomy followed by choledochoendoscopic stone extraction without biliary drainage is a safe and effective treatment of hepatolithiasis combined with choledocholithiasis.

Combination of serum tumor markers dickkopf-1,DCP and AFP for the diagnosis of primary hepatocellular carcinoma

Objective:To evaluate the detection accuracy of the biomarkers dickkopf-1,DCP and AFP as a serum biomarker panel by comparing the sensitivity of the panel with those of the individual biomarkers.Methods:The study was composed of three groups,one with HCC patients,one with non-HCC liver diseases and one with healthy controls.Serum AFP was measured using a chemiluminescence assay and serum dickkopf-1 and DCP were measured with ELISA.The sensitivity and specificity of the biomarkers were analyzed as single parameters and as a serum panel.Results:The HCC group showed higher levels of dickkopf-1,DCP and AFP than the other two groups(P<0.05).Dickkopf-1 showed better sensitivity(73.26%vx.58.13%.P<0.05) and better specificity(44.00%vs.29.00%,P>0.05) than AFP.DCP also had better sensitivity(74.42%vs.58.13%.P<0.05) than AFP,but their specificity was similar(30.00%vs.29.00%.P>0.05).The combination of the biomarkers as a scrum panel produced much better sensitivity(93.02%) and specificity(78.00%) than each of the markers individually(P<0.05).Conclusion:The combination of AFP.DCP and dickkopf-1 as a biomarker panel can significantly improve the detection power with much higher sensitivity and specificity for HCC than any of the biomarkers alone.The tests are convenient and inexpensive,and may serve as a valuable addition to current options for the diagnosis of HCC.

Anatomic resection of liver segments 6-8 for hepatocellular carcinoma

AIM:To report the devised anatomic liver resection of segments 6,7 and 8 to improve the resection rate for patients with right liver tumors.METHODS:We performed anatomic liver resection of segments 6,7 and 8 to guarantee the maximum preservation of the remaining normal liver tissue.Segment 5 was determined by two steps of Glissonean pedicle occlusion.And a"┏┛"shaped broken resection line was marked upon the diaphragmatic surface of the liver.Selective right hemihepatic inflow occlusion was used to reduce blood loss during parenchymal transection between segments 6 and 5 and between segments 8 and 5.If needed,total hepatic Glissonean pedicle occlusion was used during parenchymal transection between segment 8 and the left liver.RESULTS:Compared to right hemihepatectomy,the percentage of future liver remnant volume was increased by an average of 13.9%if resection of segments 6,7 and 8 was performed.Resection of segments 6,7 and 8 was completed uneventfully.After hepatectomy,the inflow and outflow of segment 5were maintained.There was no perioperative mortality,postoperative abdominal bleeding or bile leakage in this group.Alpha-fetoprotein(AFP)returned to the normal range within 2 mo after the operation in all the patients.One patient died 383 d postoperatively due to obstructive suppurative cholangitis.One patient suffered from severe liver dysfunction shortly after surgery and had intrahepatic recurrence 4 mo postoperatively.Postoperative lung metastasis was found in one patient.No tumor recurrence was found in the other patients and the parameters including liver function and AFP level were in the normal range.CONCLUSION:Anatomic liver resection of segments6,7 and 8 can be a conventional operation to improve the overall resection rate for hepatocellular carcinoma.

Downregulation of orosomucoid 2 acts as a prognostic factor associated with cancer-promoting pathways in liver cancer

BACKGROUND Liver cancer has a high mortality and morbidity rate throughout the world.In clinical practice,the prognosis of liver cancer patients is poor,and the complex reasons contribute to treatment failures,including fibrosis,hepatitis viral infection,drug resistance and metastasis.Thus,screening novel prognostic biomarkers is of great importance for guiding liver cancer therapy.Orosomucoid genes(ORMs)encode acute phase plasma proteins,including orosomucoid 1(ORM1)and ORM2.Previous studies showed their upregulation upon inflammation,but the specific function of ORMs has not yet been determined,especially in the development of liver cancer.AIM To determine the expression of ORMs and their potential function in liver cancer.METHODS Analysis of the expression of ORMs in different human tissues was performed on data from the HPA RNA-seq normal tissues project.The expression ratio of ORMs was determined using the HCCDB database,including the ratio between liver cancer and other cancers,normal liver and other normal tissues,liver cancer and adjacent normal liver tissues.Analysis of ORM expression in different cancer types was performed using The Cancer Genome Atlas and TIMER database.The expression of ORMs in liver tumor tissues and adjacent normal tissues were further confirmed using Gene Expression Omnibus data,including GSE36376 and GSE14520.The 10-year overall survival(OS),progression-free survival(PFS)and relapse-free survival(RFS)rates between high and low ORM expression groups in liver cancer patients were determined using the Kaplan-Meier plotter tool.Gene Set Enrichment Analysis(GSEA)was employed to explore the ORM2-associated signaling network.Correlations between ORM2 expression and tumor purity or the infiltration level of macrophages in liver tumor tissues were determined using the TIMER database.The correlation between ORM2 gene levels,tumor-associated macrophage(TAM)markers(including CD68 and TGFβ1)and T cell immunosuppression(including CTLA4 and PD-1)in liver tumor tissues and liver GTEx was determined using the GEPIA database.RESULTS ORM1 and ORM2 were highly expressed in normal liver and liver tumor tissues.ORM1 and ORM2 expression was significantly decreased in liver tumor tissues compared with adjacent normal tissues,and similar results were also noted in cholangiocarcinoma,esophageal carcinoma,and lung squamous cell carcinoma.Further analysis of the Gene Expression Omnibus Database also confirmed the downregulation of ORM1 and ORM2 in liver tumors.Survival analysis showed that the high ORM2 group had better survival rates in OS,PFS and RFS.ORM1 only represented better performance in PFS,but not in OS or RFS.GSEA analysis of ORM2 from The Cancer Genome Atlas liver cancer data identified that ORM2 positively associated with the G2/M checkpoint,E2F target signaling,as well as Wnt/β-catenin and Hedgehog signaling.Moreover,apoptosis,IFN-αresponses,IFN-γresponses and humoral immune responses were upregulated in the ORM2 high group.ORM2 expression was negatively correlated with the macrophage infiltration level,CD68,TGFβ1,CTLA4 and PD-1 levels.CONCLUSION The results showed that ORM1 and ORM2 were highly expressed specifically in liver tissues,whereas ORM1 and ORM2 were downregulated in liver tumor tissues.ORM2 is a better prognostic factor for liver cancer.Furthermore,ORM2 is closely associated with cancer-promoting pathways.

Transplantation Expression of 4-1BB molecule on peripheral blood T cells in liver transplanted patients and its clinical implication

OBJECTIVE: To investigate the gene expression of 4-1BB in peripheral blood mononuclear cells(PBMCs) and its possible significance in clinical liver transplantation.METHODS: Reverse transcription-polymerase chain reaction (RT-PCR) was used to determine the geneexpression of 4-1BB in PBMCs from 22 patients receiving liver transplantation, 13 patients with primaryliver carcinoma (PLC), and 12 healthy controls. To determine whether 4-1BB molecule is also expressedon the surface of CD4^+ and CD8^+ T cell, flow cytometry was used to analyse the phenotype of T cellsubsets from the blood of liver transplantation patients.RESULTS: 4-1BB mRNA was detected in PBMCs from stable survivors after liver transplantation, butalmost not deteeted in PBMCs from PLC patients and healthy controls. Meanwhile, 4-1BB was almost notexpressed on the surface of CD4^+ and CD8^+ T cells in healthy controls and PLC patients. A low level of4-1BB expression, however, was found on the surface of CD4^+ and CD8^+ T cells from the stablesurvivors after liver transplantation.CONCLUSIONS: This study demonstrates that although patients are stable after liver transplantation,effector T-cells can also be activated through the signal of 4-1BB molecule and persistent irmmune responseto grafts. Blockage of 4-1BB/4-1BBL pathway may benefitially reduce the clinical dosage ofimmunosuppressive agents and prolong the survival of grafts.

Pancreaticojejunostomy, hepaticojejunostomy and double Roux-en-Y digestive tract reconstruction for benign pancreatic diseases

Surgery such as digestive tract reconstruction is usually required for pancreatic trauma and severe pancreatitis as well as malignant pancreatic lesions. The most common digestive tract reconstruction techniques(e.g., Child's type reconstruction) for neoplastic diseases of the pancreatic head often encompass pancreaticojejunostomy, choledochojejunostomy and then gastrojejunostomy with pancreaticoduodenectomy, whereas these techniques may not be applicable in benign pancreatic diseases due to an integrated stomach and duodenum in these patients. In benign pancreatic diseases, the aforementioned reconstruction will not only increase the distance between the pancreaticojejunostomy and choledochojejunostomy, but also the risks of traction, twisting and angularity of the jejunal loop. In addition, postoperative complications such as mixed fistula are refractory and life-threatening after common reconstruction procedures. We here introduce a novel pancreaticojejunostomy, hepaticojejunostomy and double Roux-en-Y digestive tract reconstruction in two cases of benign pancreatic disease, thus decreasing not only the distance between the pancreaticojejunostomy and choledochojejunostomy, but also the possibility of postoperative complications compared to common reconstruction methods. Postoperatively, the recovery of these patients was uneventful and complications such as bile leakage, pancreatic leakage and digestive tract obstruction were not observed during the follow-up period.

Allolymphocyte apoptosis induced by soluble liver specific antigen

OBJECTIVE: To investigate the alloimmunogenicity of liver specific antigen and its effects onallolymphocytes.METHODS: Liver specific antigen isolated from inbred F344 rats was used as immunogen toimmunize inbred Lew rats through different immunization pathways such as low-dose long-term hindfootpad, high-dose portal vein and thymus immunization. Western blotting, DNA fragments gelelectrophoresis, mixed lymphocyte culture (MLC) and mixed lymphocyte hepatocyte culture (MLHC)were employed to analyze the immune state after immunization.RESULTS: At the time point of sampling, different degree of specific low immunoresponses appeared inall immunized groups as well as cyclophosphamide (CY) treated group. Compared with group I, othergroups expressed caspase-3 significantly as detected by using Western blotting. DNA fragment gelelectrophoresis of splenocytes showed lymphocyte apoptosis. Compared with the group I, MLC of theexperimental groups showed no significant changes except that of the group V, whereas MLHC decreasedmarkedly (P【0.05).CONCLUSIONS: Liver specific antigen not only has alloimmunogenicity to induce alloimmunoreactionbut induce antigen specific low immunoresponses and antigen specific lymphocyte apoptosis by high-doseor low-dose long-term immunization. It may be an important transplantation antigen that may lead to anovel way to liver transplantation immunotolerance.

Efficacy and safety of sirolimus early conversion protocol in liver transplant patients with hepatocellular carcinoma:A single-arm, multicenter, prospective study

Mammalian target of rapamycin(m TOR) inhibitor as an attractive drug target with promising antitumor effects has been widely investigated. High quality clinical trial has been conducted in liver transplant(LT) recipients in Western countries. However, the pertinent studies in Eastern world are paucity. Therefore, we designed a clinical trial to test whether sirolimus can improve recurrence-free survival(RFS) in hepatocellular carcinoma(HCC) patients beyond the Milan criteria after LT. This is an open-labeled, single-arm, prospective, multicenter, and real-world study aiming to evaluate the clinical outcomes of early switch to sirolimus-based regimens in HCC patients after LT. Patients with a histologically proven HCC and beyond the Milan criteria will be enrolled. The initial immunosuppressant regimens are center-specifc for the frst 4-6 weeks. The following regimens integrated sirolimus into the regimens as a combination therapy with reduced calcineurin inhibitors based on the condition of patients and centers. The study is planned for 4 years in total with a 2-year enrollment period and a 2-year follow-up. We predict that sirolimus conversion regimen will provide survival benefts for patients particular in the key indicator RFS as well as better quality of life. If the trial is conducted successfully, we will have a continued monitoring over a longer follow-up time to estimate indicator of overall survival. We hope that the outcome will provide better evidence for clinical decision-making and revising treatment guidelines based on Chinese population data.