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率列慕
4 years ago
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1 Case presentation Int. 楊佳穎指導教師 : 蘇裕傑醫師

2 Patient data ID number: R Gender: male. Date of birth: 1944/01/12 Date of admission: 2005/05/05

3 Chief complaint General malaise for 3 months.

4 Present illness This 61 years old male has history of hepatitis B, cirrhosis and GU(proved by PES 3 years ago). About 3 months ago, he found himself got tired easily. His appetite still good but sometimes he felt abdomen discomfort after meal. So he went to Hua-Chi hospital ask for help. The hepatic CT was done on 2005/04/30 and showed multiple hepatic masses with central necrosis and central necrotic metastatic lymph nodes. Lab. data showed elevated AFP, GOT, GPT and TBI, PT prolong also noticed. So he came to our hospital ask for our opinion.

5 Personal history Social history: no smoking or betel nuts chewing. Alcohol consumption: occasionally. Past history: hepatitis B, liver cirrhosis and gastric ulcer. DM and HTN: unconfirmed. Allergy: no known allergens. Family history: one of his son has liver cancer.

6 Image finding (Hua-Chi) Liver cirrhosis with lobulated hepatic surface. Splenmegaly and prominent collateral vessels and low esophageal varices. Multiple GB stones are noted. Large confluent hepatic masses with central necrosis over R t lobe, size about 10cm, and several smaller central necrotic hepatic tumors. Multiple bulky central necrotic metastatic lymph nodes over hepatoduodenal ligament, peripancreatic area and around celliac trunk are noted.

7 Lab. data AFP: >30000 ng/ml TBI: 2.6 mg/dl AST: 118 IU/l BUN: 13 mg/dl CRE: 0.8 mg/dl PT: 13.9; control: 10.0 (sec.) APTT: 31.9; control: 28.5 (sec.)

8 Discussion What can we do for this patient?

9 AJCC staging Stage IVa

10 Surgical therapy 1 Surgical resection and liver transplantation are the only chances of cure but have limited applicability. In the United States and Europe, resection is possible in only 15% of patients. The decision to resect is affected by tumor size at presentation (large) and the presence of cirrhosis and coexisting disease. A 5-year survival rate of 40% can be expected for resectable lesions, even considering the higher success rates in tumors smaller than 2 cm with no vascular invasion (T1 N0 M0, stage I).

11 Surgical therapy 2 Orthotopic liver transplantation for resectable or unresectable HCC in the setting of cirrhosis may be feasible for small, solitary, well-staged lesions; however, the prognosis for long-term survival is poor (20-30%). The limited availability of organs and long wait times make this an unrealistic option for most patients.

12 Ablative therapy Percutaneous ethanol injection Transarterial chemoembolization Radiofrequency ablation They are limited by the size and number of lesions.

13 Medical therapy To date, chemotherapy for HCC has shown unsatisfactory results. This may be caused by the universal expression of the multidrug resistance gene protein on the surface of the malignant cells, leading to active efflux of chemotherapeutic agents. The most active drugs tested include doxorubicin, cisplatin, and fluorouracil. Response rates are well under 10%, and treatment shows no clear impact on overall survival. Combination chemotherapy does not add any benefit to single-agent chemotherapy.

14 Prognosis Overall prognosis for survival depends on the extent of cirrhosis and tumor stage, which then determine the appropriate treatment. Patients able to undergo a curative resection have a median survival of as long as 4 years; patients who present when they are too ill to be treated have a median survival of 3 months.

15 Conclusion Prevention is the best way to against HCC. One who has hepatitis B and liver cirrhosis should regular follow up the AFP and echo exam. The earlier the HCC is diagnosed, the better chance we have to cure.

16 Case report 1 Hepatogastroenterology Jan-Feb;51(55): Surgical treatment in a patient with multiple implanted intraperitoneal metastases after resection of ruptured large hepatocellular carcinoma. Ryu JK, Lee SB, Kim KH, Yoh KT. Department of Internal Medicine, Pundang Jesaeng General Hospital, Sungnam, Korea. jkr1965@medimail.co.kr A 52-year-old man was admitted due to sudden abdominal pain with progressive abdominal distention. Computed tomography showed a 5x7-cm low-attenuation mass in the right hepatic lobe and hemoperitoneum was demonstrated. He was taken for emergency hepatic angiography and hepatic arterial chemoembolization was done. Ten days after embolization, right lobectomy was performed successfully. Microscopic examination confirmed hepatocellular carcinoma. After 4 months, follow-up computed tomography showed a 2-cm-sized irregular-shaped mass at the right great omentum. A second surgery for omentectomy with mass excision was performed. Three months later, splenectomy and segmental resection of the colon was performed. Five months later, metastatic lymph node was detected around the head of the pancreas. Mass excision was then performed. Microscopically, all resected tumors were confirmed as metastatic hepatocellular carcinoma. The patient underwent resection of multiple intraperitoneal metastases three times for 1 year after resection of ruptured hepatocellular carcinoma and is currently disease free for 15 months. Hepatic resection is the treatment of choice for ruptured hepatocellular carcinoma but dissemination of tumor cells in the peritoneal cavity should be kept in mind. Even if intraperitoneal metastases develop, long-term survival could be possible with aggressive surgical treatment.

17 Case report 2 Gan To Kagaku Ryoho Nov;29(11): [A patient with hepatocellular carcinoma with intraperitonial lymph node metastases in whom oral UFT treatment was markedly effective] [Article in Japanese] Imamura Y, Baba Y, Tahara K, Kubozono O, Ogura Y, Maenohara S, Moriya H. Dept. of Internal Medicine, Kagoshima Kouseiren Hospital. We report a patient with hepatocellular carcinoma (HCC) with intraperitoneal lymph node metastases in whom UFT (uracil + tegafur) was markedly effective. The patient was a 70-year-old woman with chronic hepatitis C, who developed HCC mainly infiltrating the medial segment of the liver. Arterial infusion chemotherapy and embolization were performed, and radiofrequency ablation was also conducted. Despite these interventions, the serum alpha-fetoprotein level continued to increase, and reached a level as high as 208,000 ng/ml by the second month of treatment. Abdominal computed tomography (CT) revealed no recurrence in the liver, but multiple metastases to intraperitoneal lymph nodes were identified. UFT-E treatment was initiated at the dose of 400 mg/day. A subsequent abdominal CT revealed complete disappearance of the intraperitoneal lymph node metastases 2 months after the start of UFT treatment. The serum alpha-fetoprotein level returned to normal 4 months after the start of UFT treatment. We consider that the patient described here is a good example to illustrate the remarkable effectiveness of UFT in the treatment of metastatic HCC.

18 Comment 在病患的 PE 方面要加強在 liver cirrhosis 方面, 可加入 CHILD 的分級

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<4D6963726F736F667420576F7264202D20ECFAD0C0D0C0C2DBCEC4CCE1BDBB6F7665722E646F63> 硕士专业学位论文论文题目鲍温病临床病理特征和几种治疗方法比较的分析研究研究生姓名指导教师姓名禚欣欣康定华专业名称皮肤性病学研究方向皮肤肿瘤与皮肤病理论文提交日期 2013 年 4 月 I 鲍温病临床病理特征和几种治疗