病理报告:
The surgical specimen consisted of the right lobectomied liver, measuring 19.5×14.5×11.5 cm in size, gallbladder, 9.5×4.8 cm in size, inferior vena cava, 1.5×1.0 cm in size, tumor thrombus, 2.4×1.5×0.5 cm in size. Macroscopically, a conglomerated solid tumor with white and yellow color, measuring 18×12×10 cm in size, was seen in the liver. Furthermore, a small solid tumor was seen near the main tumor. Please see the figure for tissue sampling. Histological examination revealed poorly differentiated hepatocellular carcinoma with invasion to the liver serosa (#19) into the portal vein branches, and the right hepatic vein branch. It was largely composed of a solid pattern of bizarre carcinoma cells with nuclear pleomorphism including giant cells and mitoses. A thick trabecular pattern was partly seen. Necrosis was also prominent. The carcinoma extended into the main trunk of right hepatic vein (#22), but no carcinoma invasion was seen in the inferior vena cava wall. No carcinoma invasion was seen in the sampled liver capsule with fibrosis and granulation with hemosiderin-laden macrophages. Surgical margins were negative for carcinoma. The liver showed live cirrhosis, early stage. The gallbladder showed chronic cholecystitis, mild. Eg, fc(+), fc-inf(+), sf(+), sl(rupture), vp2, vv2, bo, im 1, sm(-), lc, PT4, P stage ⅣA
病理诊断:
1.Hepatocellular carcinoma (PT4 P stageⅣA)
2.live cirrhosis
影像学,我重点讲两个片子,先讲CT:
1.是位于S5和S8的肿瘤,已经经过动脉栓塞,里面的高密度影就是碘油。
2.是肿瘤浆膜下血肿,即将破裂,栓塞后有部分机化。
3.即下腔静脉,与肝脏密度基本一致,考虑有癌栓
4.右下肝静脉,内有癌栓!
腹腔动脉造影:
1.是位于S6的satellitic lesion,因CT的层面少。没显示出来
2.是位于S5和S8的肿瘤
3.肝右动脉分出的供应肿瘤1的前区域枝A5和A8的合干
4.肝右动脉分出的供应肿瘤2的后区域枝A6和A7的合干
5.肝中动脉
6.肝左动脉
7.胃十二指肠动脉
8.肝总动脉
9.肝固有动脉
10.胃左动脉
11.脾动脉
网友[fortner]对腹腔动脉造影的分析
以上图片由网友[fortner]提供
关于此病人的诊断和治疗的思路,我简单的谈一下:
病人的病史中:
2003年9月19日 右肩及右上腹疼痛来珍。当时CT检查:肝右叶前区域肿瘤,怀疑rupture。
2003年9月22日 TAE实行 A8 栓塞,后区域肿瘤的滋养血管同样栓塞。
肝右前区域的肿瘤怀疑有破裂,此时最佳的处理方法就是手术或是栓塞,当时病人的ICGR15在30%左右,切除右半肝极易导致术后的肝衰。
而栓塞治疗肝癌即将的破裂出血,是绝对地有效,国际上有循证医学的证据,而且有缩小肿瘤,恢复肝功,制止出血的多方面功效,是某些不能一期切除的肿瘤获得了二期切除机会!
病人9月22日行栓塞,10月29日行手术,中间间隔四周多,肝功确实有恢复,而且出血得到了有效地制止,肿瘤缩小拉,肝功在child-puge分类属于A类;ICGR-15恢复到17.9%,基本是可以耐受右半肝切除。
简单说一下ICGR15:
肝癌肝切除的一个显著特点是面对硬变的肝脏,因大多数肝癌都伴有不同程度的肝硬变。这些硬变的肝脏还有多大的储备功能,还能耐受多大范围的肝切除,这是施行每例肝癌肝切除术前所要回答的问题。除常规的肝功能检查项目外,近年来较为注重肝储备功能评估的量化指标。如国内不少单位已将吲哚青绿(ICG)排泄试验列为临床日常检查项目。临床研究表明,当ICGR15<10%,表明肝脏有较大的储备功能,可行各类肝切除; ICGR15为10%~20%,肝切除范围应限制在半肝;ICGR15为20%~30%,一般仅可作肝楔形切除;若ICGR15>30%,则禁忌作任何类型肝切除。
手术如图中所示,先切除右半肝,然后腔静脉阻断,取出癌栓,手术非常顺利,出血约2000ml,术后恢复正常 ,术后六周化疗,现在已经出院!