| ObjectiveTo analyze the enhancement CT/MRI imaging characteristics of 66 HCC patients with portal vein tumor thrombus(PVTT)and contrast with the hepatic artery DSA features of first TACE treatment, and evaluate the arterial blood supply characteristics of PVTT, provide imaging evidence for the treatment of hepatic artery TACE in HCC patients with PVTT. Through analyze the outcomes of TACE combined with endovascular treatment of portal vein, try to find out new comprehensive interventional treatment for HCC patients with PVTT and to evaluate the clinical efficacy and safety, in order to greatly improve the therapeutic effect of HCC with PVTT.MethodsThe clinical data and enhancement CT/MRI imaging characteristics and hepatic artery DSA imaging data of 66 HCC patients with PVTT who were treated in Shenzhen Hospital of TCM from June 2012 to November 2015 were analyzed retrospectively. Observe the enhancement features of PVTT in enhancement CT/MR image and the liver blood perfusion change caused by tumor thrombi in the portal vein. In the 66 patients,50 were male and 16 were female, the age was from 29 to 72 years old, and the median age was 47.5 years old. According to the different interventional treatment methods,66 patients were divided into two groups: the control group was simple TACE treatment group (n=35 cases), the study group was TACE combined with endovascular treatment of portal vein treatment group (n=31 cases). Endovascular treatment group including portal vein stents implantation, linear 125Ⅰ seed strand implantation and radiofrequency catheter ablation in the portal vein.66 patients were treated with TACE for the first time, and then all the patients were treated with TACE intermittently. After the first TACE treatment,the study group was treated with endovascular treatment of portal vein in next week, and the treatment was performed by the percutaneous puncture portal vein guided by color Doppler ultrasound and DSA. The clinical data of two groups, the technical success rate,complications, clinical efficacy, laboratory test results, survival status and adverse reactions were analyzed. The lipiodol deposition of PVTT, portal vein blood flow recanalization and liver function improvement were mainly observed. Statistical methods including counting data using chi square test, measurement data using t test;survival rate calculated using Kaplan-meier method,using Log-Rank for statistical comparison.Results1. There were no significant differences between the two groups in the clinical data (including age,sex,Child-pugh, location, number, size, and distribution of portal vein tumor) (P>0.05).2. Enhancement CT/MR of 66 patients display irregular filling defect of portal vein,enhanced in varied degrees,visible network artery in or around the tumor thrombus, and visible messy collateral circulation around the liver; DSA show stripe-like, snowflake, irregular staining shadow in hepatic hilar region, irregular filling defect of portal vein, portal vein stenosis, complete occlusion of portal vein without development, cavernous transformation of the portal vein (CTPV)in the portal vein main trunk area. Arteriovenous shunting (AVS) can be found while the blood flow of cancer embolus is rich. Enhancement CT/MR and DSA have a good correlation. DSA can intuitively display the speed of blood flow in the portal vein, collateral circulation caused by PVTT,the arterial blood supply of PVTT and AVS. The lipiodol deposition of PVTT can be found after TACE, but there is a large difference in the density of iodine oil. The density of iodine oil is related to the successful rate of super selective catheterization of the branch of the blood supply artery of the tumor, and is also related to the presence of AVS.3.All 66 patients received an average of 2.5 TACE treatments.The results show that TACE effect in primary hepatocellular carcinomas and portal vein tumor thrombi are clear. After treatment, the liver function damage can be recovered to the preoperative level in 2 weeks, which indicates that the patients with hepatocellular carcinoma and PVTT have better tolerance to TACE.4.Portal vein branch puncture were successfully performed in 31 HCC patients with PVTT guided by color Doppler ultrasound and DSA fluoroscopy. Interventional instruments like guide wire, catheter et al can inserted smoothly through the portal vein tumor thrombus segment into the mesenteric vein or splenic vein. In 31 patients,15 cases of portal vein stents implantation, 9 cases of portal vein stents implantation combined with 125Ⅰ particle implantation,7 cases of portal vein stents implantation combined with portal vein tumor thrombus radiofrequency catheter ablation. After treatment, the blood flow in main portal vein is recovered and the perfusion of branch of portal vein is obvious improved. In the portal venous phase, the degree of the liver parenchyma contrast agent was increased, and the extent of staining was enlarged. Liver function improved significantly after treatment.5. The results showed that the median survival time was 12.4 months in the study group,the 0.5,1,2 year survival rates was 77.4%,58.1% and 29%, respectively;while the control group, the median survival time was 7.6 months, the 0.5,1 and 2 years survival rates were 57.1%,40%,11.4%, comparison of the survival rate of the two groups, the differences were significant (P<0.05).Conclusion1. This retrospective study showed that, the tumor thrombus is as hypervascular as the primary cancer of the liver. Tumor thrombus in mainly supplied by the branch of hepatic artery, and the branches of the duodenal artery are often involved in the blood supply of portal vein tumor thrombus.2. After TACE treatment, the iodine oil deposits were found in the tumor thrombus. This shows that TACE treatment of portal vein cancer embolus has the same therapeutic effects, PVTT can not be contraindications to TACE treatment.3. Percutaneous endovascular treatment of portal vein technique with high success rate,can immediately open portal vein blood flow, contribute to recovery of liver function. To a certain extent, TACE combined with endovascular treatment of portal vein can improve the survival rate of patients, the clinical effect of TACE combined with endovascular treatment of portal vein on primary hepatocellular carcinoma and portal vein tumor thrombus was significantly better than that of simple TACE treatment.4. This study was retrospective and limited in number of cases, and the follow-up time was still short, the curative effect still need large sample, multicenter, randomized prospective study to verify and perfect the scientific. |
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