“癌中之王”的肝癌其实并没有人们想像的那么可怕。在现代医学飞速发展的背景下,很多病人经过医生合理的综合治疗和疏导帮助,在与肝癌的长期斗争中,最终战胜了癌魔。从现代医学的角度看,肝癌也不再是所谓的“癌中之王”,慢性肝炎、肝硬化也不再是不治之症。关键是普及相关的医学知识,让病人找对医生并予以及时、合理的综合治疗。那么,战胜肝癌,你需要知道些什么? 晓书 范嵘 战胜肝癌首先要了解肝癌 肝癌是指发生于肝脏的癌症。如果是肝脏内的细胞所引发的癌病,称之为“原发性肝癌”;由身体其他器官的癌症转移到肝脏而形成的肝脏恶性肿瘤,称为继发性肝癌,也称“转移性肝癌”。 原发性肝癌,从形态上,大体分型为巨块型、结节型号和弥漫型。从病理上主要可分为肝细胞肝癌、肝内胆管细胞癌、混合型癌。其中肝细胞肝癌是肝癌中的最常见的类型,约占90%以上。80%以上是肝细胞肝癌合并有肝硬化,约50%肝硬化病人合并肝癌。因此对肝硬化病人必须密切追踪观察,定期复查。 我国80%以上的肝癌发病原因与乙肝、丙肝病毒感染有关。黄曲霉素、食物及水源的污染、寄生虫病、肝硬化等,还有饮酒、吸烟、遗传因素也与肝癌发病有关。 乙型肝炎病毒感染是我国肝癌发病的主要原因。我国有1.2亿乙肝病毒携带者。目前对乙肝的治疗仍没有特效药物,因此,注射乙肝疫苗是预防乙肝的最好办法。接种后80%可免受乙型肝炎病毒的感染。对于乙肝患者,使用α干扰素和拉米夫定等抗病毒药物可以有效的减少肝炎的波动,亦减慢了肝硬化的进展,从而减少了肝癌的发生。 积极防治病毒性肝炎,对降低肝癌发病率有重要意义。乙肝病毒灭活疫苗预防注射不仅防治肝炎有效果,对肝癌预防也必将起一定作用。避免不必要的输血和应用血制品,可以有效防止感染乙肝或其他血液传播性疾病。 肝癌早期通常没有明显的临床症状与体征。到了中、晚期则会出现肝区疼痛、上腹肿块、腹胀、腹泻、恶心、厌油、呕吐、食欲减退、体重下降、消瘦乏力、发热、黄疸、甚至会出现恶病质及出血倾向。一旦出现上述一些症状,则应高度警惕,立即到医院就诊,选择合理的检查如抽血化验甲胎蛋白(AFP)水平、肝脏 B超及CT检查以便及时确诊治疗。 其实,肝癌的早期发现并不难,是各种实体癌中最容易发现的一种。采用现代的诊断方法,直径1厘米的肝癌就可发现。 肝癌普查最好的模式仍是甲胎蛋白和B 超相结合。甲胎蛋白是肝癌最好的定性诊断方法,目前仍未有其他检查超过它,甲胎蛋白在肝癌发生的早期即可检测到。近年来医学影像学的进步相当大,CT已经广泛普及并成为肝癌检查的常规项目,高分辨CT可发现1厘米大小的肝癌,绝大多数的肝内肿物经 CT、B 超及其他影像学手段相结合检查后都可以得到确诊。 战胜肝癌重在管好自己的嘴 肝癌的发生与生活习惯息息相关。特别是与“吃”有关。因此,战胜肝癌一定要管好自己的嘴! 长期进食霉变食物、含亚硝胺食物、微量元素硒缺乏是促发肝癌的重要因素。 黄曲霉毒B1是目前已被证明有明确致癌作用的物质,主要存在于霉变的粮食中,如玉米、花生、大米等。另外摄食大量的含有亚硝酸盐的油炸或腌制食物,可致亚硝酸盐在体内蓄积不能及时排出,并在体内转变成亚硝胺类物质,这类物质有直接致癌作用。 俗话说“饮酒伤肝”。其实,饮酒并不是肝癌的直接病因,但它的作用类似于催化剂,能够促进肝癌的发生和进展。有长期酗酒嗜好者容易诱发肝癌。这是因为酒精进入人体后,主要在肝脏进行分解代谢,酒精对肝细胞的毒性使肝细胞对脂肪酸的分解和代谢发生障碍,引起肝内脂肪沉积而造成脂肪肝。饮酒越多,脂肪肝也就越严重,进而引起肝纤维化、肝硬化、肝癌的发生。如果肝炎患者再大量酗酒,会大大加快加重肝硬化的形成和发展,促进肝癌的发生。 预防肝癌还应注意饮食中营养物质的平衡,不可偏食,平时要多吃蔬菜、水果、粗粮,少吃精米、精面、动物性脂肪和低纤维素食物。如果食用发霉的花生来下酒,诱发肝癌的可能性会更大。此外,腐烂的鱼、肉中含有大量的胺,腐烂的蔬菜、水果以及反复煮开的水中,含有大量的亚硝酸盐。亚硝酸盐极易与胺结合生成致癌物亚硝胺。 而粗粮、蔬菜、水果,由于含有丰富的矿物质、维生素,对预防肝癌很有利。 战胜肝癌需要克服心理恐惧 由于东西方文化的差异,在中国,一旦病人生癌,医生首先告知的是家属,由家属决定是否告知病人本人;而在西方国家正好相反,一旦生癌,医生首先是告知病人,有病人安排自己的治疗及生活,因为西方人对癌症有正确的认识,因此大多数病人能够正确面对,并调整自己的心境。 而在我国大多数老百姓都是谈癌色变,尤其对肝癌缺乏足够的认识,因此给病人带来的不仅是身体的折磨,更是心理的沉重负担。很多患者不能忍受这种痛苦,出现各种劣性情绪,最终失去了生活的信心与勇气。一些肝癌患者,与其说死于疾病,不如说是被肝癌吓死的!良好的精神心理状态有助于抗击肝癌,这已是人类的共识。实际上,无论患有什么样的疾病,最可怕的并不是疾病本身,而是患者对于疾病的恐惧和沮丧,使他们完全失掉了生活的勇气。 从医学角度来讲,良好的心理状态,常有利于机体自身的免疫系统去对抗癌细胞。因此合理疏导肝癌病人的心理,让病人能认识到,即使患了肝癌,也不能逃避,而应采取积极、主动、坦然处之的态度,尽量保持良好的精神状态,坚定康复的信念,配合医生积极治疗,对于稳定和改善病情,提高其生存质量,延长生存期是十分有益的。着急、悲伤、忧郁于事无补,只会加重病情。 战胜肝癌需要规范化个体化 肝癌的治疗方法有很多。过去,肝癌的治疗仅有外科、化疗和放疗三大法宝。上世纪80年代以来,兴起了肝癌的局部治疗,如放射介入、超声介入等。 目前肝癌最好的治疗方法仍是手术。手术切除可一次切除整个癌瘤,使体内达到完全的无瘤状态。手术切除效果最好的是小肝癌,其五年生存率可达60%; 大肝癌切除后也可获得30%左右的五年生存率。 尽管手术是治疗肝癌最为有效的方法,但由于肝癌发病隐匿,很多肝癌患者就诊时已是肝癌晚期,丧失了手术机会,但并不是说这些患者就此丧失治疗机会。除手术治疗外,肝癌的治疗方法还有:放射介入、超声介入、放射治疗、局部消融、放射性粒子植入、化学药物、生物制剂、中医中药等治疗手段。 可以说十八般兵器各显神通。对不能切除的肝癌,放射介入是首选的局部治疗方法。 放射介入是将导管经皮插入到肝血管内,注射药物到肿瘤周围及瘤内。最常用的是经皮肝动脉栓塞化疗(TACE),通过向肝肿瘤的供血动脉注入栓塞剂和化疗药,达到饿死和杀死肿瘤细胞的双重作用。超声或CT介导下的局部治疗方法也繁多,有瘤内注入无水酒精,冰醋酸,热盐水等;有用冷冻、微波、射频、高功能聚焦超声等。其性质都一样,大同小异,不是用水攻,就是火攻或冷攻,总之,利用各种武器使肿瘤局部产生的高温或低温,导致肿瘤组织的凝固坏死。这类疗法安全简便,疗效确实,特别适用于不能手术或拒绝手术的肝癌患者。当然在治疗局部肿瘤的同时,对于伴有乙肝或丙肝的患者,还要同时联合抗病毒治疗。有条件的还可以使用分子靶向药物(索拉菲尼),通过抑制肝癌细胞的血管生成生长来达到缩小瘤体且防止转移的双重功效。另外适当的免疫增强治疗也是提高患者抵抗恶性肿瘤能力的重要环节。
Background: Pseudoaneurysms (PAs) are common vascular abnormalities predominantly arising from a disruption in the integrity of the arterial wall. The potential complications of PAs are usually unpredictable and carry high rates of morbidity and mortality. This paper presents our experience with various treatment strategies for PAs.Methods Fifty-four patients with 55 PAs were diagnosed by non-invasive imaging examination. The etiology of PAs included trauma (33/55), infection (5/55), iatrogenic (6/55), and idiopathic (11/55). Different procedures including ultrasound (US)-guided compression, endovascular treatment, and surgery were performed depending on the location of PAs, size of the sac and neck, and characteristics of the donor artery. The methods of endovascular treatment included embolization of parent artery, the PA sac, or implantation of a stent-graft. Follow-up was performed using US or CT and ranged from 1 day to 24 months (average 16.7 months).Results In all 54 patients, 3 patients with superficial PAs were treated by US-guided compression, while 44 patients with 45 PAs located in the head and neck (n=20), viscera (n=10) or extremities (n=15) were treated by endovascular treatment. Nine patients with PAs located in the head and neck (n=2) or extremities (n=7) were treated by surgery. Among them, one patient underwent endovascular treatment combined with surgery and 1 was treated by surgery after unsuccessful US-guided compression. In the 3 patients treated with US-guided compression, 2 were successfully treated while the remaining patient required additional surgery. Primary technical success of endovascular management was 97.7% (43/44) and the cure rate was 95.5% (42/44). In the surgery group, 4 patients recovered well, 1 patient was cured by endovascular treatment combined with surgery, 2 cases underwent amputation, 1 patient died of multi-organ failure and 1 patient was paralysed.Conclusions Minimally invasive interventional techniques are established treatment methods for PA with favorable success rates and minimal morbidity. The therapeutic options should be tailored to the location, size and rupture risk of PA, condition of the donor artery and existing comorbidity.Chin Med J 2011;124(12):1784-1789
ABSTRACTPurpose: To evaluate the retrievability and safety of the G2 filter.Materials and Methods: A retrospective study of all G2 filter retrievals at a single institution was conducted. Hospital records and imaging studies were reviewed for complications, and factors affecting retrieval were analyzed.Results: From 2005 to 2009, a total of 139 patients presented for retrieval of their G2 filter, and 131 pairs of pre- and post-placement cavagrams and 39 computed tomography scans were available for analysis. The following findings were recorded: limb penetration (n 33), tilt greater than 15° (n 22), local migration greater than 2 cm (n 17), retained thrombus within the filter (n 16),deformity (n 10), inferior vena cava (IVC) occlusion (n 3), fracture (n 2), and pulmonary embolism breakthrough (n 2)A total of 118 filters were removed, with a mean indwelling time of 131.8 days (range, 3–602 d). Indwell time ( 90, 90–180, or 180 d)did not affect retrieval (P .4). There were 21 filters (15.1%) left in situ as a result of severe tilt (n 9), significant thrombus in the filter (n 5), IVC occlusion (n 3), filter incorporation into the caval wall (n 3), or lack of central venous access (n 1).There was a strong relationship between penetration and caudal migration (P .0001). Severe tilt was associated with prolonged fluoroscopic times for retrieval (P .003).Conclusions: The majority of G2 filters can be removed without difficulty. The most common factor affecting retrieval was severe tilting. The indwelling time had no impact on retrieval. G2 filter–related complications were frequent but most, including fractures, were clinically insignificant.
AbstractPurpose To retrospectively evaluate the role of the Amplatzer Vascular Plug (AVP) in proximal splenic arteryembolization (SAE) compared with coils.Materials and Methods Forty patients had proximal SAE performed with AVP(s) or coils as the primary embolic agent for splenic artery steal syndrome (n = 23), trauma (n = 5),portal hypertension (n = 5), bleeding due to pancreatic pathology (n = 4), and pre-splenectomy (n = 3). Comparisons were made of occlusion and procedure time, cost, and radiation dose.Results Eighteen proximal SAE procedures were successfully performed with AVP. Twenty-two procedureswere performed with coils, including one failed AVP attempt, which was completed with coils. Precise deployment without migration was achieved in all 18 AVP cases.Seven of 22 (31.8%) coil procedures had distal migration without consequence. There was no statistically significantdifference in mean occlusion time (24.4 min for AVP vs.31.5 min for coils, P = 0.13), procedure time (43.7 min for AVP vs. 53.8 min for coils, P = 0.16), or cost ($1474.13 for AVP vs. $1722.51 for coils, P = 0.69). There was significant difference in radiation dose (842 mGy for AVPvs. 1,309 mGy for coils, P = 0.04). Fourteen of the 18 (78%) AVP devices required additional embolic material.Conclusions AVP with additional embolic agents is a useful alternative for proximal SAE because of precisedeployment, resistance to migration, and radiation reduction. AVP use may be limited by vessel tortuosity. Theocclusion time, procedure time, and cost were reduced but this was not statistically significant due to the need for additional embolic material.
中心静脉置管在国外已有20多年的应用经验,目前在美国,每年大约有500万根中心静脉导管的安插,它为患者化疗、补液、营养、采血等提供了方便。中心静脉导管通常分单腔中心静脉导管、双腔中心静脉导管、三腔中心
淋巴管造影早国内很少有医院做,在美国做的医院也不多,相对来说淋巴管造影对诊断淋巴管阻塞以及淋巴管损伤性瘘等疾病价值很大。但因为Procedure比较麻烦,再加上CT和核素的应用,所以做的就越来越少。 在CLEVELAND CLINIC看的这台淋巴管造影患者是一种少见病,叫Gorham综合症(Gorham-Stout Syndrome,简称GSS)是一种非常罕见和神秘的疾病,主要特征是大量骨头莫名其妙的被溶解或者消失,其骨组织被大量增生的淋巴组织所替代。这个病人的骨盆包括耻骨和坐骨已经被破坏得非常严重。 淋巴管造影先是在趾蹼之间注射美兰,等待足背的淋巴管显影后在第一和第二趾间足背的淋巴管表面,尽量现有下方开始切开皮肤,充分分离淋巴管,用的器械都是需要血管外科或脑外科分离的微手术器械,分理处淋巴管后,肉眼看只有1~2mm左右,非常细,因此需要用上脑外科的手术放大眼镜,分离好之后又用一种特殊的固定装置,将分好的淋巴管置于这个装置上,流出端先暂时阻断以充盈淋巴管,此时可见内有美兰,预放好丝线,然后用很细的注射针穿刺淋巴管,成功后即以玻璃丝接出外
到了克里夫兰CLINIC FOUNDATION已经一个月了,今天遇上一例少见病---THROMBOSIS OF SMV(肠系膜上静脉血栓),这种CASE比较少见,多见于凝血功能障碍,或者继发于胰腺炎或腹部手术之后。在小肠缺血病变中,由于SMV THROMBOSIS引起的只占5%~15%。这种疾病以非特异性腹痛为首发症状,持续性呕吐,腹泻和血水样便比动脉栓塞更为多见。体检时可见腹胀、腹部压痛、反跳痛和腹肌紧张。肠鸣音减弱或消失。腹腔穿刺可抽到血性液体。常有发热和白细胞计数、红细胞压积增高。腹部X线平片可显示受累小肠扩张充气,伴有气液平面。透视时肠蠕动消失。目前无创检查主要以CT加CTA为主,传统手术和抗凝治疗30天内死亡率可达13%~50%。随访急性SMV THROMBOSIS 3年死亡率为36%。而在度过30天之后,其生存率即可达到88%。因此如何使之顺利度过30天则成为治疗关键。 目前治疗主要以内科抗凝溶栓为主,外科则以手术切除坏死肠管和取栓为主,介入治疗则包括经肠系膜上动脉间接溶栓治疗、经皮经肝导管内机械取栓加溶栓治疗。介入治疗目前国内主要以前者为多,而在美国也只是在一些大的医院像M CLINIC, JOHNS HOPKINS,CCF等这样的大医院具备机械取栓和溶栓的条件。今天的这例患者也是特发性SMV THROMBOSIS,外院转到CCF,已经3天了,外院做了CT提示SMV及PV血栓。WBC及PTT增高。CCF也是很少遇见这样的CASE,于是经过讨论认为可先做TIPS建立通道再机械取栓溶栓,但是经过近2个半小时尝试发现该患者肝静脉与门脉右支的角度关系非常复杂,很难穿到。于是再选择经皮经肝途径,经CO2造影引导,经腋中线肝右叶直接穿刺门静脉的右下肢分支,然后依次置入导丝导管等建立通道,造影证实主要血栓位于SMV与门静脉主干交汇部一下均显影不佳,仅过反复机械随栓取栓,采用了ANGIOJET以及机械碎栓导管,还用了FORGTY球囊导管及长鞘抽吸血栓。这些在国内价格都比较昂贵,一般患者很难承受。这时候才真正体会到在美国这个富裕国家做介入PROCEDURE的感觉,一个字---爽,想用什么就用什么不用去考虑患者家属或患者的经济情况,在台上只有一个目的就是顺利完成PROCEDURE,一切为了病人治病出发。不像在国内,我就因为给病人做胸部小肿块活检,用了两个穿刺针(因穿刺针是进口针不在医保之列)而遭到家属的质问甚至恐吓。所以有此比较,可见在国内做医生比在美国要难多了,更多的时候医生要把一些精力花费在和病人以及病人家属解释各种方法的费用,然后根据费用以及相应方法治疗疾病的效果提供选择,宗旨是既要看得好又要少花钱,这是国内医疗市场患者及医生所具备的基本原则。 这个患者经过这样的干预,似乎改善了不少,但是因为手术时间漫长,长达5个小时,因此没有达到完全消除血栓,于是再植入COOK专用溶栓导管用小剂量TPA溶栓。因为前面做了TIPS,穿刺次数较多,也不敢用量太大,主要怕出血并发症。当然具体效果如何还有待观察。
【摘要】 目的 评价中晚期肝内胆管细胞(ICC)介入治疗效果及分析影响介入疗效的相关因素。方法 回顾性分析2007年9月至2014年12月经病理诊断为肝内胆管细胞癌患者的临床资料。77例患者中,51例行介入治疗(包括经皮肝动脉化疗栓塞术(TACE)及TACE联合射频消融术或碘125粒子置入术,归为介入组),26例行全身静脉化疗(化疗组)。统计分析ICC介入治疗患者的总生存期、肿瘤客观反应率及影响介入疗效的相关因素,同时观察介入治疗后的不良反应和并发症。结果 介入组:6个月、12个月、18个月生存率分别为70.6%、50.5%及35.4%,中位生存期为12.1月(95%CI 8.43-15.77);肿瘤客观缓解率及疾病控制率分别为29.4%、70.6%。化疗组: 6个月、12个月、18个月年生存率分别为46.2%、7.7%及0%,中位生存期为5.5月(95%CI 3.38-7.61)。单因素分析显示介入治疗组患者中位生存期显著高于全身静脉化疗组(P<0.05)。对影响介入组患者预后多因素分析显示,CA125浓度、TMN分期及是否有外科根治术史是影响这类患者预后的独立因素。介入治疗的副作用主要为骨髓抑制、栓塞后综合征及肝功能损害,均为Ⅰ-Ⅱ级。未出现与介入治疗相关的严重并发症。结论 中晚期ICC行介入治疗是安全可行的,可以控制病情进展及延长患者生存期。 【关键词】 肝内胆管细胞癌;介入治疗;肝动脉化疗栓塞术;全身静脉化疗 The application of interventional management in the treatment of advanced intrahepatic cholangiocarcinoma LI Wan-ci, Zhu Xiao-li*, WANG Wan-sheng, CHEN Tao, SHEN Jian. Department of Interventional Radiology, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province 216006, China Corresponding author: ZHU Xiao-li, E-mail: zhuxiaoli90@163.com 【Abstract】 Objective To retrospectively evaluate the efficacy of interventional therapy in the treatment of patients with advanced intrahepatic cholangiocarcinoma (ICC) , and to analyze the factors that may affect the prognosis. Methods A total of 77 patients of pathologically proved advanced ICC, encountered during the period from September 2007 to December 2014, were enrolled in this study. Of the 77 patients, interventional therapy, which included transarterial chemoembolization(TACE) or combined with percutaneous radiofrequency ablation(RFA) or 125I seed implantation was performed in 51(interventional therapy group),while only systemic chemotherapy was employed in 26(chemotherapy group). The overall survival, efficacy and influencing factors on the prognosis of interventional therapy group were analyzed. Procedure-related adverse events and complications were also reviewed. Results For the interventional therapy group, the 6-,12-, and 18-month overall survival(OR) rates were 70.6%,50.5% and 35.4% , respectively(median survival time 12.1 moths) and 46.2%,7.7% and 0%, respectively (median survival time 5.5 moths), for the chemotherapy group . The objective response rate(ORR) and disease control rate(DCR) for interventional therapy group were 29.4% and 70.6% respectively. The univariate analysis revealed that the survival period was significantly longer in interventional therapy group than in chemotherapy group (p
子宫动脉栓塞术(UAE)在临床应用已有20余年的历史,主要用于治疗妇科和产科的急性出血、妇科肿瘤及血管畸形等。1994年,法国学者首次报道应用UAE以减少子宫肌瘤术中出血时发现,患者在接受UAE治疗后出血症状停止、肌瘤缩小,有些患者经UAE治疗后获临床痊愈。随着放射影像学技术的提高和栓塞材料的不断改进,UAE治疗子宫肌瘤以其创伤较小、方法简捷、患者易接受等优点而迅速发展起来。 那么哪些子宫肌瘤适合介入栓塞治疗呢? 一般而言,对于中年妇女月经量较大,甚至引起贫血,或有痛经等临床症状的子宫肌瘤,核磁共振检查除外带蒂的浆膜下肌瘤、粘膜下小于5cm的肌瘤、宫颈管肌瘤后,均可行介入栓塞治疗。 方法:局麻下,将圆珠笔芯粗细的导管经右侧腹股沟韧带下的股动脉穿刺后置于相应供应子宫的动脉内,造影显示肌瘤的血管情况;根据DSA影像表现,超选择插管至子宫动脉,行子宫动脉造影术,观察子宫动脉的走行及子宫体造影的染色、病灶分布情况等。根据子宫动脉粗细及病灶大小、分布情况,注入特殊的栓塞颗粒完成对子宫动脉栓塞后,即可拔出导管及导管鞘,压迫穿刺点10min后加压包扎,右下肢制动12h,住院3~10d。UAE的副反应主要为:(1)栓塞后综合征:包括下腹疼痛(90%以上)、发热(约为25%)、不规则阴道出血或阴道分泌物增多(约为25%)及恶心、呕吐;对症处理均可改善;(2)下肢酸胀无力(50%~60%);无需特殊处理;(3)坏死组织滞留和排出]。多数学者认为,UAE后严重并发症的发生率较低,约为1%。UAE的主要并发症有穿刺部位血肿、感染,附壁血栓,剧烈腹痛,盆腔及其他部位脏器的局部缺血、坏死,子宫内膜炎和子宫不可逆坏死,腹膜后血肿,卵巢功能低下和短暂闭经,以及术后尿潴留、子宫瘘道形成、败血症等。
Application of Middle Sacral Artery and Lumbar Artery Angiography in the Treatment of Sacral neoplasmDepartment of Interventional Radiology, No 1 Affiliated Hospital, Suzhou University, Jiangsu, 215006【ABSTRACT】 Objects To determine the embolization values of middle sacral aretery and lumbar artery in the treatment of sacral neoplasm. Materials and Methods Among all 63 sacral neoplasm cases, CT and MR were analyzed retrospectively. Select angiography and embolization of the tumor vessels were also performed before operation in all patients. Angiographies include bilateral internal iliac arteries, sacrum middle artery and relevant lumbar artery. Results Among all 63 sacral neoplasm cases, istopathology revealed: 27chordomas, 10 giant cell tumors, 6 neurogic tumors, 5 metastasis tumors and 15 other type tumors. DSA revealed 36 cases belong to hypervascular type tumor while 27 cases belong to hypovascular type tumor. In addition supplied by the illiac arteries, 22 cases supplied by middle sacral aretery, while 15 cases supplied by lumbar artery in hypervascular type tumors. 23 cases showed rather satisfactory effect during operation after embolizaion, 15 cases showed satisfactory, 13 cases showed mild satisfactory with 3 cases not satisfactory. Conclusions Sufficient supply artery embolization should be performed in the treatment of sacral neoplasm. More supply artery such as middle sacral aretery and lumbar artery should be revealed and embolized except for internal iliac artery in the hypervascular type neoplasm cases. 【Keywords】 Sacral neoplasm; Middle sacral aretery; Lumbar artery; Embolization 骶骨肿瘤是一少见病变,不同骶骨肿瘤影像学表现亦有不同,其血供亦有其相应的特点,而由于骶骨的解剖学特性及其血供复杂的特点,使得外科手术常因术中失血过多而影响手术视野,术前双侧髂内动脉栓塞常可有效提高骶骨肿瘤的全切率,减少术中出血,减少术后并发症,降低死亡率。但仍有部分患者在栓塞后术中出血较多,考虑可能与供血动脉未能全部栓塞有关,尤其与骶正中动脉(Middle Sacral Artery, MSA)和腰动脉参与供血有关。回顾分析1992年~2006年我院骶骨肿瘤63例,全部病例均行影像学检查及DSA下靶血管造影及栓塞治疗,现报道如下。资料与方法一、一般资料63例骶骨肿瘤患者中,男30例,女33例,年龄22岁~83岁,平均年龄45.2岁。脊索瘤27例,其中复发7例;巨细胞瘤10例;神经鞘瘤6例,转移性肿瘤5例,淋巴瘤3例,囊肿3例,软骨肉瘤2 例,其它少见肿瘤7例:成骨肉瘤、梭形细胞癌、滑膜肉瘤、原始神经外胚层瘤、侵袭性纤维瘤、节细胞神经瘤、原发性恶性化学感受器瘤各1例。54例经手术病理证实,6例经活检病理证实,3例为临床综合诊断。二、 方法全部63病例均行常规X线,CT检查,其中39例行MR检查(T1WI/T2WI/Gd-DTPA-T1WI)。DSA检查包括双侧髂内动脉造影,了解髂内动脉参与血供情况,肿瘤血管特性及与影像学诊断符合程度;常规均行双侧髂内动脉栓塞后以猪尾巴导管行腹主动脉造影了解双侧髂内动脉是否完全栓塞,同时可了解是否有MSA、腰动脉参与供血,如有供血则可采用4.1 F cobra导管成袢后插入MSA及腰动脉对相应的供血血管行栓塞。全部栓塞均以明胶海绵条和颗粒进行,明胶海绵条大小约10mm×2mm×2mm大小,颗粒大小约2mm×2mm×2mm左右。栓塞结束以透视下注射造影剂仅见靶血管主干,而所有分支消失为止。54例手术者均在栓塞后1~7天手术。结果一、血管造影表现:63例骶骨肿瘤患者中,按肿瘤血管显示程度分为乏血供和富血供两种类型。乏血供者27例,造影表现为供血动脉区无明显新生肿瘤血管或少量增粗肿瘤血管,实质期无明显肿瘤染色或少量肿瘤染色(图1)。其中良性肿瘤6例,以神经鞘瘤和囊肿为主;恶性肿瘤14例,以低度恶性脊索瘤为主(详见表1)。富血供者36例,造影表现为供血动脉区明显新生肿瘤血管,实质期肿瘤染色明显(图2)。其中良性肿瘤14例,以巨细胞瘤为主;恶性肿瘤22例。除髂内动脉供血外,MSA参与供血者22例,腰动脉参与供血者15例(详见表1)。二、栓塞及并发症情况:全部病例均顺利完成双侧髂内动脉栓塞,对MSA参与供血的22例患者,有3例无法选择性插管而放弃MSA栓塞;对腰动脉参与供血的15例患者均成功选择性插管栓塞;除3例MSA无法选择性插管患者,余肿瘤染色在栓塞后均消失至90%以上。63例患者中有8例患者在栓塞后出现不同程度臀部肌肉酸痛,一周后缓解;余无特殊并发症。三、术中出血情况:54例骶骨肿瘤栓塞后手术出血量在100ml-7000ml之间,平均出血量为1028±1207ml。其中手术效果满意者(术中出血不超过400ml)23例;较满意者(术中出血在400ml-1200ml之间)15例;尚满意者(术中出血在1200ml-2500ml之间)13例,不满意者(术中出血>2500ml)3例,其中1例复发脊索瘤患者、1例巨细胞瘤患者、1例成骨肉瘤患者,这3例中有2例MSA有供血但无法栓塞。手术中无1例出现失血性休克和死亡。表1 63例骶骨肿瘤血供特点分布表病理类型乏血供富血供MSA参与供血腰动脉参与供血良性肿瘤巨细胞瘤01064神经鞘瘤3341囊肿3000节细胞神经瘤0110恶性肿瘤脊索瘤16(2)11(5)66转移瘤1400淋巴瘤2110软骨肉瘤1102滑膜肉瘤0110梭形细胞癌0110成骨肉瘤0110原始神经外胚层瘤0101侵袭性纤维瘤0111原发性恶性化学感受器瘤1000合计27362215注:括号内为复发脊索瘤讨论外科手术是治疗绝大多数骶骨肿瘤的主要方法,但由于其血管丰富致术中出血多,使彻底切除困难,局部复发率高。由于骶前、骶旁、骶骨及骶管内血供来自双侧髂内动脉、MSA及腰动脉,其间有广泛吻合支相互吻合,另外骶骨松质骨多,再加上肿瘤血管增生增粗,内部及周围血池形成,吻合支及静脉血管广泛,所以术中出血多且不易止血。而术前选择性肿瘤血管栓塞可有效地减少术中出血量,降低手术的危险性,从而为根治手术创造了条件,因此骶骨肿瘤术前栓塞成为十分有价值的辅助治疗手段[1]。骶骨肿瘤随其性质不同其血供特点亦有很大差异,良、恶性骨肿瘤不但在微血管密度上有差异,而且两者的血管分布形式也有较大区别[2]。本组研究发现,良性肿瘤中除巨细胞瘤及部分神经鞘瘤表现为富血供性外,余良性肿瘤如神经鞘膜囊肿等则表现为乏血供型为主。巨细胞瘤则大多表现为富血供型,且常有MSA或腰动脉参与供血,Lin 对18例骶骨巨细胞瘤行动脉栓塞术,研究发现骶骨巨细胞瘤常表现为肿块较大且血供丰富,供血动脉常包括MSA、腰动脉、髂内动脉、髂腰动脉、臀上、下动脉及直肠上动脉[3]。本组10例均为富血供型,除髂内动脉参与供血外,另有6例MSA和4例腰动脉参与供血,其中3例MSA和腰动脉同时参与供血。而恶性肿瘤大多数表现为富血供型,本组表现为乏血供者有16例脊索瘤和软骨肉瘤、原发性恶性化学感受器瘤及转移瘤各1例,脊索瘤中16/27为乏血供型,可能与其低度恶性有关。血管造影在鉴别巨细胞瘤和富血供恶性肿瘤时常较困难,而MRI动态增强常有助于两者的鉴别[2]。正常MSA解剖位置变异较大,Tribus研究了37具尸体发现MSA宽度平均2.5mm,25例中9例距L5-S1椎间隙上缘中线平均超过5mm,13例距L5-S1椎间隙下缘中线平均超过5mm[4]。MSA在主动脉造影上常不易显示且插管困难。但当骶骨或骶周区域有富血管肿瘤生长时,骶正中动脉常可增粗,分支增多。此外在盆腔动脉粥样硬化或既往有双侧髂动脉栓塞后引起盆腔或下肢血循环障碍的情况下长可作为增生的侧枝通路[5]。本组63例栓塞前行双侧髂内动脉造影,栓塞后行双侧髂总动脉分叉处造影了解有无骶正中动脉或腰动脉是否参与血供,如有参与血供者,则以4.1 F Cobra导管成袢后对供血的MSA及腰动脉逐支行超选择性插管,Cobra导管成袢后可增加导管嵌入血管开口的稳定性,有效防止栓塞剂返流。本组22例骶正中动脉和15例腰动脉参与供血者大多为富血供肿瘤,这与文献描述骶正中动脉在病理情况下增粗增多亦相符合[5]。骶骨肿瘤的所有供血血管均应栓塞,如没有将肿瘤所有供血动脉全部栓塞,则术中仍有发生大出血的可能。在现代介入止血方法应用之前,骶骨肿瘤手术出血一般在3000~10000 ml,手术常因出血凶猛且无法控制而导致肿瘤切除不彻底,或出现失血性休克导致严重并发症甚至危及生命[6]。Gellad[7]等认为满意的术前栓塞结果应达到肿瘤染色消失75%,术中出血量应小于3000ml。本组54例术前栓塞后除3例不满意外,其余术中出血均小于2500ml。因此骶骨肿瘤术前栓塞除需栓塞双侧髂内动脉外,有时还需了解是否有MSA和邻近腰动脉参与供血,对于多血供肿瘤者应尽量栓塞彻底以减少术中出血。参考文献[1]. 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