所有的病案已经上传，请GZ帮我看看，有没癌症可能？？？

君君668

这次检查结果出来后，看结果我们再和您联系看怎么办？

君君668

http://www.hbver.com/Article/gyhjqt/gazl/200412/3441.html刘医生，您看看这个.。

liver_GZ

至于抗病毒治疗方案的调整：
上述的情况在抗病毒治疗初期是获得了病毒学应答，随着治疗的延长出现了病毒学突破甚至反跳，属于继发性治疗失败。这种情况多说明病毒出现了耐药变异。
下一步很可能发生ALT的突发（flare）、或肝炎flare、甚至恶化。
因此，有必要提前预防，及时给予联合或换药治疗。
由于原来应用的拉米夫定，可以选择拉米夫定联合阿德福韦等的抗病毒治疗方案。

liver_GZ

我找到了原文：
Am J Surg. 2004 Aug;188(2):165-7.
A case of rapid intrahepatic dissemination of hepatocellular carcinoma after radiofrequency thermal ablation.Nicoli N, Casaril A, Hilal MA, Mangiante G, Marchiori L, Ciola M, Invernizzi L, Campagnaro T, Mansueto G.

BACKGROUND: Radiofrequency ablation (RFA) is a novel technique for the treatment of liver malignancies that is becoming increasingly more popular because of its feasibility, effectivity, repeatability, and safety. However, an increased number of complications after RFA has been reported in literature. The aim of this paper is to discuss the possible role of RFA in rapid intrahepatic spreading of hepatocellular carcinoma (HCC). PATIENTS AND METHODS: We treated a 66-year-old woman who had a 3.5-cm HCC with two courses of percutaneous RFA using a modified needle with seven hooks. The effectiveness of the treatment was assessed 1 month later by enhanced computed tomography. RESULTS: Two courses of treatment were needed owing to the nodule position (close to the inferior vena cava). Computed tomography scan performed 1 month after the second RFA showed an intrahepatic arteriovenous fistula. Angiography performed after 1 month showed a rapid intrahepatic spreading of HCC. CONCLUSIONS: Radiofrequency ablation can create an arteriovenous fistula that can facilitate migration of tumoral cells from the nodule to the hepatic portal system and rapid intrahepatic dissemination of HCC.
其实细细斟酌，这篇文章的结论其实是站不住脚的：
一般情况：一66岁的女性肝癌患者，其肝癌直径3.5厘米，由于肿瘤位置靠近下腔静脉，行两次射频治疗。治疗1月后采用增强CT评价疗效。
结果：第二次射频治疗1月后CT发现肝内动静脉瘘，再1个月后动脉造影证实肝癌已迅速肝内播散。
置疑：
RFA后发生的仅仅是先后时间顺序上的两个事件，如何证实“肝内动静脉瘘”和“肝癌已迅速肝内播散”两者之间存在因果关系？作为解剖位置靠近下腔静脉的肿瘤，穿刺后产生“肝内动静脉瘘”如果作为肝癌扩散的肇事方，也应该多是肝动脉－肝静脉属枝之间的内瘘，转移灶应该是进入“肝内动静脉瘘”的流出道——下腔静脉内，此处的门静脉属枝应该都很细小，造成门静脉内瘘的机会偏少。
此外，该处的一个小肝癌，需要两次RFA、且RFA的操作后发生动静脉瘘，他们的技术有待提高。
所以，他们的结论并不具有代表性“Radiofrequency ablation can create an arteriovenous fistula that can facilitate migration of tumoral cells from the nodule to the hepatic portal system and rapid intrahepatic dissemination of HCC.”

liver_GZ

提供两篇文献：
1. 肝活检HCC针道转移的发生率为2.7％。
Gut 2008;57:1592-1596
Needle track seeding following biopsy of liver lesions in the diagnosis of hepatocellular cancer: a systematic review and meta-analysis
M A Silva1, B Hegab1, C Hyde2, B Guo2, J A C Buckels1, D F Mirza1

Background: Needle biopsy of a suspicious liver lesion could guide management in the setting of equivocal imaging and serology, although it is not recommended generally because there is the possibility of tumour dissemination outside the liver. The incidence of needle track seeding following biopsy of a suspicious liver lesion is ill-defined, however.

Methods: A systematic review and meta-analysis of observational studies published before March 2007 was performed. Studies that reported on needle tract seeding following biopsy of suspicious liver lesions were identified. Lesions suspected of being hepatocelleular cancer (HCC) were considered. Data on the type of needle biopsy, diagnosis, incidence of needle track seeding duration to seeding, follow-up and impact on outcome were tabulated.

Results: Eight studies identified by systematic review on biopsy of HCC were included in a meta-analysis. The pooled estimate of a patient with seeding per 100 patients with HCC was 0.027 (95% confidence interval (CI) 0.018 to 0.040). There was no difference whether a fixed or random effects model was used. Q was 4.802 with 7 degrees of freedom, p = 0.684; thus the observed heterogeneity was compatible with variation by chance alone. The pooled estimate of a patient with seeding per 100 patients per year was 0.009 (95% CI 0.006 to 0.013), p = 0.686.
Conclusions: In this systematic review we have shown that the incidence of needle tract tumour seeding following biopsy of a HCC is 2.7% overall, or 0.9% per year.


2. 肝活检的肿瘤种植发生率为2.29% ( 0-11%)；无水酒精注射联合肝活检为1.4% (1.15-1.85%) ，RFA不联合活检为0.61% (0-5.56%)，RFA联合肝活检则为 0.95% (0-12.5%)。
Cancer Treat Rev. 2007 Aug;33(5):437-47.
Seeding following percutaneous diagnostic and therapeutic approaches for hepatocellular carcinoma. What is the risk and the outcome? Seeding risk for percutaneous approach of HCC.Stigliano R, Marelli L, Yu D, Davies N, Patch D, Burroughs AK.

BACKGROUND: Tumour biopsy is usually considered mandatory for patient management by oncologists. Currently percutaneous ablation is used therapeutically for cirrhotic patients with small hepatocellular carcinoma (HCC), not suitable for resection or waiting for liver transplantation. However malignant seeding is a recognized complication of both diagnostic and therapeutic procedures in patients with HCC. Although percutaneous therapy whether with or without biopsy of a suspected HCC nodule may minimize the risk of seeding, this has not been confirmed.
AIM: To evaluate the risk of seeding, defined as new neoplastic disease occurring outside the liver capsule, either in the subcutaneous tissue or peritoneal cavity following needle biopsy and/or local ablation therapy (LAT).
METHODS: A literature search resulted in 179 events in 99 articles between January 1983 and February 2007: 66 seedings followed liver biopsy, 26 percutaneous ethanol injection (PEI), 1 microwave, 22 radiofrequency ablation (RFA), and 64 after combined biopsy and percutaneous treatment (5 microwave; 33 PEI; 26 RFA).
RESULTS: In 41 papers specifying the total number of patients biopsied and/or treated, the median risk of seeding was 2.29% (range 0-11%) for biopsy group; 1.4% (1.15-1.85%) for PEI when used with biopsy and 0.61% (0-5.56%) for RFA without biopsy, 0.95% (0-12.5%) for RFA with biopsy and 0.72% (0-10%) for liver nodules (including non-HCC nodules) biopsied and ablated.
CONCLUSION: Risk of seeding with HCC is substantial and appears greater with using diagnostic biopsy alone compared to therapeutic percutaneous procedures. This risk is particularly relevant for patients being considered for liver transplantation.

因此，总体上，RFA治疗肝癌被认为是微创、安全的。

君君668

首先，非常感谢您这么详细耐心的解答。我相信您所说的一定没错!
另外，我爸这次的检查结果出来了。
11月12日查的血凝报告：
1.凝血酶原时间　　13　　11－14
2.凝血酶原时间（INR）　　1.11　　0.85-1.55
3.部分凝血活酶时间　　40.5↑　　21-35
4.纤维蛋白原含量　　231.5　　200-400
5.纤维蛋白原时间　　8.7　　5.3-10

8月20日查的血凝报告：
1.凝血酶原时间　　17.3↑　　11－14
2.凝血酶原时间（INR）　　1.14　　0.85-1.55
3.部分凝血活酶时间　　44.9↑　　21-35
4.纤维蛋白原含量　　129.2↓　　200-400
5.纤维蛋白原时间　　15.0↑　　5.3-10

对比8月20号的，有明显的改善。

11月12日HBV-DNA数据：
HBV-DNA：1.644*10E4

10月7日：
DNA：1.63*10E6

对比10月7号的数据，也降了。

11月13号甲胎蛋白的数据
甲胎蛋白：98.4
9月19日甲胎蛋白数据：187
9月26日----------：201.7
10月9日----------：173.4
10月23日---------：117.6

对比以前的数据，基本上算是持续下降。

11月12日肝功数据：
丙氨酸氨基转移酶  47↑  0-45
前蛋白  8.2↓ 10-40
总蛋白  82.3↑ 60-80
白蛋白：38↓  40-50
球蛋白：44.3↑  20-30
总胆总素：18.3  0-19.1
直接胆红素：5.0  0-7
门冬氨基酸氨基转移酶：63↑ 6-37
r-谷氨酰转移酶：77↑  5-54
腺苷脱氨酶：36↑ 0-25

出院后一周的肝功能化验报告单：

01前白蛋白 10-40   7.2↓
02总蛋白  60-80   83.6 ↑
03白蛋白  40-50   34.6 ↓
04球蛋白  20-30   49↑
05总胆红素  0-19.1  28.7↑
06直接胆红素  0-7  15.2 ↑
07丙氨酸氨基转移酶 0-45  48↑
08R-谷氨酰转移酶  5-54   44
09腺苷脱氨酶  0-25   37↑

10月6日肝功数据：
总胆红素：16.9　　　2-20
谷丙转氨酶：47↑　　＜40
总蛋白：76　　60-80
白蛋白：47　　35-55

看来，我爸的肝功不太稳定。

11月12号血常规报告中有几项不太正常：
1.白细胞  3.81↓  4-10
2.中性细胞绝对值  1.03↓ 2-7.5
3.淋巴细胞绝对值  2.12  0.8-4.0
4.单核细胞绝对值  0.45  0.1-0.8
5.嗜酸细胞绝对值  0.15  0-0.7
6.嗜碱细胞绝对值  0.05  0-0.2
7.中性细胞百分数  27.1↓ 51-75
8.淋巴细胞百分数  55.6↑  20-40
9.单核细胞百分数  11.9↑ 3-8  
10.嗜酸细胞百分数  4.02  0-7
11.嗜碱细胞绝百分数  1.4  0.2.5
12.红细胞  3.73↓ 4-5.5贫血？
13.血红蛋白  130  120-165
14.红细胞压积  37.7  40-50
15.红细胞平均体积  101  
16.红细胞平均血红蛋白  34.7
17.平均血红蛋白浓度  344  320-360
18.红细胞分布宽度  12.7  10-16
19.血小板  83↓ 100-300脾功能亢进？
20.血小板压积  0.08  0.08-0.32
21.血小板平均体积  9.64  7.6-10.6
22.血小板分布宽度  17.2  16-20

就这些了。刘医生，您帮我们看看。这些数据说明了什么呢？我特别希望是好的结果。

[ 本帖最后由 君君668 于 2008-11-17 09:36 编辑 ]

君君668

今天一直等着......

君君668

我爸第一次住院是在和平医院，医生就想让做肝动脉造影。后来在省二院，医生也是让做肝动脉造影。他们谁也没提射频消融治疗。做这个手术的技术要求是不是很高？做不好会有继发感染或者癌细胞转移？另外，相比较而言，我爸这种情况是不是适合做射频消融治疗？您说它是微创、安全的？

liver_GZ

16楼处贴出的动态化验结果，很直观，便于分析。

抱歉，先纠正一下我上面的发言，抗病毒治疗后明显抑制DNA复制，无需换药。建议定期复查。

目前状态持续向好，应予坚持。

上述两家医院都建议动脉造影，估计应是用于诊断。不会是直接行肝动脉栓塞化疗（TACE）吧（dayang战友有此遭遇）？

对于诊断，估计你们仍有怀疑。
个人观点：勿枉勿纵，尤其不能心存侥幸。
目前临床诊断HCC明确（当然，我仅是从文字描述了解CT结果；可能中间会和真实CT情况有误差）。
当然，1－2个月后复查，密切随访，未尝不可。

射频消融技术，通常需要影像技术的引导（超声引导或CT引导），操作并不复杂。

射频消融的风险很小，相较于肝切除，是公认的微创、更安全的肝癌治疗措施。
因为肝癌手术切除，面临着大切口、更大的生理创伤，由于手术操作对肿瘤的挤压、搬动，甚至肿瘤术中破裂等情况，你说可能发生的风险，哪个更大？

对于能切除的肝癌，不提倡术前或单纯选择TACE。

君君668

刘医生，您说‘目前临床诊断HCC明确’是什么意思？明确我爸就是肝癌？
对于射频消融术，在您在这个贴子提到这个词之前，我对它一无所知。要不是您提到它，我们还以为，我爸如果真的是肝癌，只能进行肝动脉造影了呢。谢谢您，刘医生，让我们知道了一个更好的肝癌治疗措施。


‘目前临床诊断HCC明确（当然，我仅是从文字描述了解CT结果；可能中间会和真实CT情况有误差）。
当然，1－2个月后复查，密切随访，未尝不可。’

是不是确认我爸就是肝癌？急切期盼您的回复。