Interventional treatment of hepatocellular liver cancer (hepatocellular carcinoma) has been widely used and has achieved remarkable results. We review and discuss some special issues with the experience of 3500 cases of hepatocellular carcinoma interventions in the past 10 years, in order to further improve the level of hepatocellular carcinoma interventions.
1.Hepatocellular carcinoma combined with portal vein cancer thrombosis and its treatment:
The literature reports that the incidence of portal vein thrombosis combined with hepatocellular carcinoma is as high as 20%-60%. In the past, it was once thought that portal vein thrombosis was a contraindication to transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma. However, the prognosis for hepatocellular carcinoma combined with portal vein embolization is very poor.
Nishimura et al. reported that the 1-, 2-, 3-, 4-, and 5-year survival rates after embolization chemotherapy for hepatocellular carcinoma were 74%, 47%, 29%, 18%, and 10%, respectively, in the absence of portal vein thrombosis; 41%, 18%, 12%, 8%, and 6%, respectively, in the absence of portal vein thrombosis; 20%, 6%, 3%, 3%, and 0%, respectively, in the presence of portal vein trunk thrombosis. The survival rates were 41%, 18%, 12%, 8% and 6% for portal vein trunk embolism and 20%, 6%, 3%, 3% and 0% for portal vein trunk embolism. The management of portal vein cancer embolism can be divided into two aspects.
(1) Direct embolization treatment: angiography found that the portal vein cancer thrombus is still mainly supplied by hepatic artery, and CT scan after embolization treatment confirmed that there is iodine oil deposition in the cancer thrombus. Therefore, it is feasible to use microcatheter for TACE via hepatic artery selective cannulation, which can shrink or even disappear the cancer thrombus to a certain extent.
(2) Palliative treatment: We have tried to perform portal vein trunk cancer thrombus removal by transjugular intrahepatic portosystemic shunt, or direct treatment by transjugular intrahepatic portosystemic shunt, or percutaneous transhepatic puncture of portal vein to place stent to recanalize portal vein. Through the above treatment, the patient’s portal vein pressure significantly decreased and ascites significantly reduced or disappeared.
2.Hepatocellular carcinoma combined with arteriovenous fistula and its treatment.
The appearance of arteriovenous fistula seriously affects the efficacy of TACE for hepatocellular carcinoma and aggravates portal hypertension and liver function damage. Hepatocellular carcinoma combined with arteriovenous fistula can be divided into two cases, one is hepatic arteriovenous fistula and the other is hepatic arteriovenous fistula.
Digital subtraction imaging of hepatic artery can clearly show the occurrence of both arteriovenous fistulas and the degree of shunt. If a hepatic arteriovenous fistula is found, multiple injections of anhydrous ethanol should be used to occlude the fistula by percutaneous anhydrous ethanol injection, and then TACE should be performed. The fistula was then retreated to the vicinity of the fistula and embolized with a hairy steel ring and/or anhydrous ethanol.
We have treated 50 patients with hepatic arteriovenous fistula and 26 patients with hepatic arteriovenous fistula according to the above method, and found that the iodine oil chemotherapeutic agent could be deposited in the lesion better.
3. Hepatocellular carcinoma combined with Borchard’s syndrome and its management.
The incidence of hepatocellular carcinoma combined with Borchard’s syndrome is not uncommon, and some domestic and foreign literature reports its incidence as high as 30%-47%. There are four main reasons for the complication of hepatocellular carcinoma with Borchard’s syndrome.
(1) Mechanical compression by tumor;
(2) Direct tumor erosion of veins;
(3) Cancer thrombosis;
(4) secondary thrombosis. In Berger’s syndrome, the inferior vena cava is predominantly involved, with a few cases involving the hepatic vein, and the inferior vena cava may be partially or completely narrowed.
For such patients, inferior vena cava stenting is an effective method to quickly relieve the obstruction, and further treatment of the primary tumor can be done after stenting. For patients with cancer thrombosis, hepatic arteriography can also be used to understand whether there is blood supply to the cancer thrombus. Stenting can also avoid the risk of pulmonary infarction caused by cancer thrombus and thrombus dislodgement.
4.Hepatocellular carcinoma combined with bile tumor and its treatment.
Biliary tumor combined with hepatocellular carcinoma often occurs after interventional treatment of hepatocellular carcinoma, and the physical and chemical effects of TACE and/or percutaneous local ablation cause necrosis of tumor or bile ducts in the corresponding area, and bile spills and wraps to form pseudocyst. Its incidence is reported to be 0.9% abroad and 3.1% in our data. Bile tumor has no obvious symptoms in early stage, but it can cause obstructive jaundice by compressing the bile ducts to a certain extent, and secondary infection of bile tumor can cause symptoms similar to liver abscess.
The diagnosis is mainly based on CT, which shows one or more cystic or columnar hypodense foci with clear or indistinct borders next to the lesion, with CT values of 20-30 HU in the early stage and gradually decreasing to watery density thereafter. Percutaneous percutaneous cholangioma angiography shows that it is not connected to the bile duct, but increasing pressure injection can show a fistula connected to the bile duct. In the management, if there are no clinical symptoms, internal anti-inflammatory and biliary treatment may be the mainstay or not treated; if there are clinical symptoms, percutaneous drainage should be performed.
Some people inject fibrin clotting factor at the same time of drainage, and we injected anhydrous ethanol to sclerosis after several days of drainage, and found that the cystic cavity could be gradually reduced or disappeared.
5. Combined liver abscess after hepatocellular carcinoma intervention and its management.
The incidence of abscess is reported by different scholars, with 3.3% reported by Mutsumasa Takahashi in Japan, 2.6% reported by Reed et al, and 1.4% in our data.
Foreign literature reports that the culture of pus are all Clostridium perfringens, and the culture of 7 cases in our hospital is Garcinia cambialis in 2 cases, Flavobacterium spp. in 2 cases, Flavobacterium spp. in 1 case, Candida albicans in 1 case, and Escherichia coli in 1 case. the main clinical manifestation of liver abscess formation after TACE is fever, up to 39.5℃～41℃ for more than 2 weeks, with chills fever, accompanied by pain in the liver area of different degrees, therefore Therefore, if there is unexplained persistent and prolonged high fever with liver pain after TACE, abscess formation should be thought of, and ultrasound or CT examination of the liver should be performed immediately.
Once liver abscess formation is detected, percutaneous hepatic puncture should be performed to drain the abscess, and the abscess cavity should be flushed with antibiotic saline, followed by timely application of sensitive antibiotics according to bacterial culture results. If the pus drains freely and the infection is controlled, further treatment of the cancer will be facilitated; otherwise, it will lead to sepsis, peritonitis, and death due to systemic failure.