Volume 101 ·  Issue 28 ·  2021

Liver cancer is a common and lethal cancer, and surgery is the main treatment. In recent years, with the development of various technologies, more and more new strategies of the treatment for liver cancer have been applied in clinical practice and are helpful to increase the radical resection rate and improve the prognosis of patients. Based on the advances in surgical treatment of liver cancer, this paper aims to discusses some hot issues in preoperative, intraoperative, postoperative and translational therapy.

Molecular targeted drugs are the main means of treating advanced liver cancer. In order to better guide the rational, effective and safe application of targeted drugs in clinical practice, the Liver Cancer Professional Committee of Chinese Medical Doctors Association organized experts in relevant fields, and after many discussions and revisions based on relevant clinical research and medication experience, this consensus was finally formed.

To investigate the effects of four therapeutic methods in the comprehensive treatment of China liver cancer staging (CNLC)Ⅱa~Ⅲa stage multiple hepatocellular carcinoma.

A retrospective study was conducted to collect clinical data of patients with multiple hepatocellular carcinoma (CNLC stage Ⅱa-Ⅲa), who received transhepatic arterial chemoembolization (TACE group, 73 cases), radiofrequency ablation (RFA group, 70 cases), TACE combined RFA (TACE combined RFA group, 69 cases) and surgical resection combined RFA (surgical resection combined RFA group, 57 cases) in the First Hospital of Lanzhou University from January 11, 2010 to January 31, 2017. The general data of age, gender, primary tumor, and laboratory examination were collected. The differences in overall survival rates and the survival rates among stratified subgrouping with different clinical factors between the four groups of patients were compared by the Kaplan-Meier method. Cox proportional hazards regression model analyzed the prognostic factors.

A total of 269 patients were enrolled and there were 194 males and 59 females with a median age of 58 years ranging from 23 to 84. The TACE group′s 1, 3, and 5-year survival rates were 43.5%, 10.2%, and 0, respectively. The RFA group were 46.3%, 17.7%, and 0, respectively. The TACE combined RFA group were 56.8%, 21.5%, and 2.3%, respectively. The surgical resection combined RFA group was 76.5%, 38.7%, and 3.8%, respectively. The surgical resection combined RFA group has the best outcome(P<0.05). Univariate analysis showed that surgery combined RFA, tumor diameter<5 cm, no vascular invasion, preoperative AFP≤400 μg/L and TB<34 μmol/L are protective factors to improve the survival prognosis of patients with CNLCⅡa~Ⅲa stage multiple hepatocellular carcinoma(HR=0.784,0.718,0.633,0.846,0.617;all P<0.05). Multivariate Cox analysis showed that surgery combined RFA, tumor diameter<5 cm, preoperative AFP≤400 μg/L were independent risk prognostic factors for CNLCⅡa-Ⅲa stage multiple hepatocellular carcinoma (HR=0.702,0.743,0.647;all P<0.05).

Surgical resection combined RFA is an effective method for the treatment of stage Ⅱa-Ⅲa hepatocellular carcinoma. Surgical resection combined RFA has more advantages in treatment patients with complicated hepatocellular carcinoma whose diameter<5 cm, tumor number<3, and preoperative AFP≤400 μg/L. Surgical resection combined RFA, tumor diameter<5 cm, preoperative AFP≤400 μg/L are independent influencing factors for the survival prognosis of patients with complicated hepatocellular carcinoma.

To explored the effect of preoperative antiviral therapy on the prognosis of microvascular tumor thrombi patients, and to established a prognostic prediction model for these patients after radical resection of liver cancer.

The clinicopathological and survival data of hepatocellular carcinoma patients with microvascular tumor thrombus who underwent radical resection in the Third Affiliated Hospital of Sun Yat-sen University from January 1, 2013 to December 31, 2015 were retrospectively collected. Kaplan-Meier method was used to calculate the survival curve, and log-rank test was used to compare the prognosis of patients with and without antiviral treatment before operation. Univariate and multivariate Cox proportional hazard regression model was used to screen predictive factors. R software was used to make predictive nomogram, and discrimination and calibration degree were used to evaluate the prediction model.

Among all 153 patients, 22 were female and 131 were male, aged (51.3±11.7) years. The preoperative antiviral therapy significantly improved overall survival and recurrence-free survival (χ²=41.423, 54.389; both P<0.001). According to the results of multivariate and regression analysis, preoperative antiviral therapy (HR=0.301,95%CI:0.171-0.532,P<0.001), alpha fetoprotein (HR=1.226,95%CI:1.157-1.776,P=0.032) and tumor size (HR=1.008,95%CI:1.001-1.016,P=0.02) were important prognostic factors for overall survival. The area under curve value of 3-year survival prediction model was 0.749(95%CI: 0.712-0.782), and that of 5-year survival prediction model was 0.755(95%CI: 0.724-0.793), with good calibration.

Preoperative anti hepatitis B virus(HBV) therapy can significantly improve the prognosis of patients with hepatocellular carcinoma complicated with microvascular tumor thrombus, we develope the prediction models of 3-year and 5-year survival rate that can improve the reference for clinical work and benefit patients.

To explore the application value of three-dimensional reconstruction of liver based on computer software in preoperative evaluation of precise hepatectomy for complex primary liver cancer.

The clinical data of patients in Peking University People′s Hospital Hepatobiliary surgery with complicated primary liver cancer from September 17, 2019 to December 20, 2020 were analyzed retrospectively. Preoperative enhanced CT/MR data of patients were collected, and 3D reconstruction of liver was performed in IQQA®-3D Liver system. The liver volume of patients was calculated, the size and location of tumor were described, and the relationship between tumor and intrahepatic bile duct, portal vein, hepatic artery and inferior vena cava was described. Preoperative decision-making and treatment plan were made to compare the compliance of the actual operation plan with the planned operation plan under the guidance of three-dimensional reconstruction.

Among all 10 patients, there were 6 males and 4 females, aged 36 to 75 years. There were 6 cases of Child-Pugh grade A and 4 cases of B liver function. There were 5 cases of portal vein variation and 5 cases of hepatic artery variation. The range and M(Q₁,Q₃)of actual liver volume measured by 3D reconstruction in 10 patients was 895- 2 477 cm³ and [1 444(1 001, 1 854)] cm³;the nodule volume was 7-1 808 [133(50, 566)] cm³;the nodule volume in the liver was 0.8%-73.0% [11.0(3.3,32.7)]% and the number of suspected lesions was 1-7. In the end, 6 patients received surgical treatment;3 received chemotherapy, and 1 received conservative treatment. The preoperative three-dimensional reconstruction of liver anatomy and tumor location of the patients receiving surgical treatment were basically consistent with the intraoperative situation. There was no case of liver failure or death during perioperative period.

In the preoperative evaluation of precise hepatectomy for complex primary liver cancer, 3D reconstruction can improve the rationality of treatment and the surgeon′s understanding of the anatomical characteristics of the liver, so as to select the best treatment for patients, which has great application value.

To assess the accuracy of the American Joint Committee on Cancer (AJCC) 8th edition staging system for hepatocellular carcinoma (HCC) and to make an appropriate modification.

Data of patients diagnosed with HCC who underwent surgery were extracted from 2004 to 2015 within the SEER database. Overall survival (OS) and disease-specific survival (DSS) of patients were analyzed.

A total of 7 911 patients were included and there were 2 117 females and 5 794 males. The male-to-female ratio was 1.00: 0.36. There were 4 050 patients older than 60 years old. Tumor size ranged from 24 to 65 mm. Tumors with single lobes (80.8%) or single lesions (62.8%) were more common. There were 230 cases and 2 052 cases received radiotherapy and chemotherapy, accounting for 2.9% and 25.9%, respectively. The median follow-up was 42 months. Analysis of the 8th edition of AJCC staging system showed that the survival curves of ⅣA stage and ⅢA stage intersected in both OS and DSS, and the differences were not statistically significant between them (both P>0.05). Analysis of patients in subgroup of ⅣA stage showed that there was no statistically significant difference in the four groups of T1N1M0/T2N0M0, T2N1M0/T3N0M0, T3N1M0/T4N0-1M0 and T3N1M0/T1-4N0-1M1 (allP>0.05). Therefore, the modified 8th edition of the AJCC staging system was proposed after retaining the definition of T/N/M in the old edition: ⅠA and ⅠB stages were retained; ⅣA stage was split: T1N1M0 was included in Ⅱ stage, T2N1M0 in Ⅲ stage, and Ⅳ stage included T3N1M0, T4N0-1M0 and T1-4N0-1M1. Cox proportional risk regression analysis of the modified 8th edition of the AJCC staging showed that significant differences were observed among the four groups, with ⅠB/ⅠA (HR=1.462, 95%CI:1.294-1.651), Ⅱ/ⅠB (HR=1.091, 95%CI:1.003-1.186), Ⅲ/Ⅱ (HR=2.034, 95%CI: 1.793-2.307) and Ⅲ/Ⅳ (HR=1.374, 95%CI: 1.192-1.583) for OS, respectively. The similar findings were seen in DSS, with ⅠB/ⅠA (HR=2.007, 95%CI:1.671-2.411), Ⅱ/ⅠB (HR=1.140, 95%CI:1.023-1.271), Ⅲ/Ⅱ (HR=2.344, 95%CI: 2.018-2.724) and Ⅲ/Ⅳ (HR=1.391, 95%CI:1.180-1.639), respectively.

The modified AJCC 8th edition staging system could predict the survival outcome of HCC more accurately.

To explore the association of systemic immune-inflammation index (SII) with protein-energy wasting (PEW) and prognosis in maintenance hemodialysis (MHD) patients.

A multicenter cohort study was conducted in 11 hemodialysis centers of Guizhou province from July to September 2019. The patients were divided into the PEW group and non-PEW group. After 12 months of follow-up, death was the endpoint event. Multivariate logistic regression analysis was used to assess the independent risk factors of PEW in MHD patients. The receiver operating characteristic (ROC) curve analysis was performed to evaluate the predictive value of SII for PEW, and the optimal cut-off value of SII was calculated. The Kaplan-Meier method was used to draw the survival curve, and log-rank test was employed to compare the difference of survival rate between the two groups.

A total of 859 patients were included [540 males and 319 females, aged (54±15) years], and there were 220 cases (25.6%) and 639 cases (74.4%) in PEW and non-PEW groups, respectively. SII was higher in the PEW group than that of the non-PEW group [600 (440, 915) vs 475 (353, 633), P<0.01]. Multivariate logistic regression analysis showed that SII was an independent predictor for PEW (OR=1.001, 95%CI: 1.000-1.002, P=0.02). ROC curve analysis showed that the area under the curve for SII to predict PEW in MHD patients was 0.725 (95%CI: 0.683-0.766), with the sensitivity and specificity of 69% and 70%, respectively. All patients were followed up for 12 months, and 45 died (with a mortality rate of 5.24%). Patients were divided into SII>520 group and SII≤520 group according to the optimal cut-off value, and subsequent Kaplan-Meier survival analysis showed that the 1-year cumulative survival rate of the SII>520 group (92.3%) was lower than that of SII≤520 group (97.1%) (χ²_log-rank=9.707, P=0.002). Further subgroup analysis revealed that, in PEW patients with MHD, the 1-year cumulative survival rate of the SII>520 group (88.5%) was also lower than that of SII≤520 group (92.3%) (χ²_log-rank=7.226, P=0.007).

SII is an independent risk factor for PEW in MHD patients, and the higher the SII level, the lower the long-term survival rate and the prognosis.

To evaluate the clinical effect of oral contraceptive (OC) pretreatment on the outcome of gonadotropin releasing hormone antagonist (GnRH-a) protocol in patients with non-polycystic ovary syndrome.

From January 2017 to May 2019, a total of 436 patients undergoing in vitro fertilization and embryo transfer/Intracytoplasmic sperm injection (IVF-ET/ICSI) treatment in Peking University First Hospital reproductive center clinic were included in this retrospective cohort study. A total of 144 patients (147 cycles) used OC pretreatment prior to GnRH-a protocol and 292 patients (306 cycles) used GnRH-a protocol without OC pretreatment. The drug usage as well as pregnant outcomes between groups were examined. The primary outcome was the cumulative clinical pregnancy rate of oocyte retrieval cycle and the secondary outcome included the number of oocytes, MⅡ oocytes, embryos and clinical pregnancy rate of fresh embryo transfer cycle.

The median ages (and Q₁, Q₃) of OC pretreatment group and non-OC group were 33 (30,36) and 34 (30,38) years old, respectively. The number of MⅡ oocytes was higher in OC pretreatment group (7/9) than in non-OC group (6/8) (P=0.002). The significant difference were not found in the cumulative clinical pregnancy rate of each oocyte retrieval cycle (61.7% vs 54.6%), the clinical pregnancy rate of fresh embryo transfer cycle (34.4% vs 35.6%), and the number of oocytes (9 vs 8) and embryos (6 vs 6) between groups.

Our findings suggest that compared to non-OC pretreatment group, pretreatment with OC is associated with more MⅡ oocytes, and with an increasing trend of the cumulative clinical pregnancy rate in non-polycystic ovary syndrome patients undergoing fresh IVF-ET/ICSI.

To explore the diagnostic cut-off value of Claudin-1 (Cla-1) in papillary thyroid carcinoma (PTC) and the efficacy of the multiple test.

Clinical and pathological data were collected from 295 patients with PTC and 137 patients with benign thyroid lesions (BTL) admitted to two hospitals in Pingdingshan City, Henan Province from January 2015 to June 2020. The expression index of Cla-1, the positive expression rate of high molecular weight cytokeratin (HMW-CK) and the negative expression rate of leukocyte differentiation antigen 56 (CD56) were calculated according to the results of immunohistochemistry. Receiver operating characteristic (ROC) curve was used to determine the cut-off value of Cla-1 for diagnosing PTC. Cla-1+HMW-CK, Cla-1+CD56, HMW-CK+CD56 and Cla-1+HMW-CK+CD56 were tested in series, and the diagnostic efficacy was evaluated by sensitivity, specificity and accuracy.

The age of PTC patients M (P₂₅, P₇₅) was 48.0 (41.0, 55.0) years old, among which 230 cases were male (78.0%). The age of BTL patients M (P₂₅, P₇₅) was 53.0 (46.0, 61.0) years old, including 34 males (24.8%). Cla-1 detection was conducted in all PTC and BTL patients, whereas only 198 and 97 cases conducted HMW-CK detection, 242 and 136 cases conducted CD56 detection, respectively. The M (P₂₅, P₇₅) of Cla-1 expression index in PTC was 80.0% (45.0%, 90.0%), which was higher than that in BTL [0.0 (0.0, 2.0%)] (P<0.001). The positive expression rate of HMW-CK was 93.9% (186/198) in PTC, and was negative in all BTL. The negative expression rate of D56 was 89.7% (217/242) in PTC, higher than that of BTL [1.5% (2/136)] (P<0.001). When expression index 19.0% was set as the cut-off value of Cla-1 for diagnosing PTC, the area under the ROC curve (AUC) was the maximum [AUC (95%CI): 0.981 (0.969, 0.994)], and the sensitivity, specificity and accuracy were 92.2% (272/295), 98.5% (135/137) and 94.2% (407/432), respectively. In multiple tests for diagnosis of PTC, the sensitivity ranged from 89.3% to 94.7%, specificity were all 100.0% and accuracy ranged from 93.1% to 96.9%.

Cla-1 expression index ≥19.0% could be set as a cut-off value for the diagnosis of PTC and serial test of Cla-1 combined with HMW-CK(CD56) improves diagnostic specificity.

To investigate risk factors associated with pulmonary embolism in women during pregnancy or peripartum. Information of 7 pregnant women diagnosed pulmonary embolism (PE) were collected from January 2018 to December 2020 in Beijing Friendship Hospital. Four non-PE pregnant women as control group were matched with each patient by age, BMI and pregnancy complications during the same period. Binary logistic regression was used to identify the potential risk factors by the comparison of difference between groups. The laboratory indices, including platelet, hemoglobin, prothrombin time, partially activated prothrombin time, D-dimer, triglyceride, total cholesterol, low density lipoprotein (LDL) and high density lipoproteinage (HDL) showed no significant difference between groups. D-dimer and HDL were found to be associated with PE during pregnancy (P<0.05). D-dimer and HDL might be associated with PE during pregnancy.

Quantitative analysis was performed on the biphasic CT of 40 patients [43-80 (66.1±9.0) years old, including 37 males] with stable chronic obstructive pulmonary disease (COPD) to measure the percentage of emphysema (Emph%); the percentage of small airway disease (SAD%) and the square root of the wall area of hypothetical airway with internal perimeter of 10 mm (Pi10). Based on the cluster analysis of Emph%, SAD% and Pi10, the patients were divided into five imaging phenotypes including no obvious imaging abnormality type (n=11), small airway disease-dominant type (n=9), bronchial wall thickening-dominant type (n=8), emphysema-dominant type (n=6) and mixed type (n=6). Patients with the same Global Initiative for Chronic Obstructive Lung Disease (GOLD) grade had similar degree of airflow limitation, but the lesion components were not identical. Being different from the traditional imaging classification, even in the cases of mild emphysema, they can be further divided into small airway disease-dominant type and bronchial wall thickening-dominant type according to the difference of airway disease.

Glomus tumor is a rare soft tissue tumor, accounting for about 2% of all soft tissue tumors. It often occurs in the dermis or nail bed, but rarely in the viscera, while bronchial glomus tumor is even rarer. This paper reports a case of glomus tumor of left main bronchus with massive hemoptysis as the main manifestation, which recovered well without recurrence after left main bronchial sleeve resection, left hemicarina resection and reconstruction, and mediastinal lymph node dissection. This case reminds clinicians that bronchial glomus tumor has a risk of massive hemoptysis and asphyxia, and the treatment mode needs to be decided after comprehensive evaluation of individual circumstances.

Metastatic liver cancer refers to a single or multiple cancer foci formed by the primary tumor formed at the extrahepatic site that metastasizes to the liver and colonizes the liver. Because of the dual blood supply of hepatic artery and portal vein, the liver has become the most common parenchymal organ for most malignant tumor metastasis. As an effective complementary method, surgery has been paid more and more attention in the treatment of metastatic liver cancer. However, at present, the proportion of patients who meet the indications for resection is small, the risk of postoperative recurrence is high, and the overall prognosis of metastatic liver cancer is still poor. This article reviews the surgical treatment of metastatic hepatocellular carcinoma in order to provide a reference scheme for clinical practice.

Liver cancer is the most common cause of cancer-related death worldwide. Most patients are diagnosed at an advanced stage, so systemic treatment has attracted much attention. Immune checkpoint inhibitors and targeted drugs have shown good therapeutic effects in patients with advanced liver cancer, but their overall efficacy in monotherapy is poor. This article reviews the progress of immune checkpoint inhibitors, targeting and combination therapy in advanced hepatocellular carcinoma.

Hepatocellular carcinoma is the most common liver malignancy. In China, its morbidity and cancer death rate have long ranked first in the world. Surgery is still the treatment of choice, but the vast majority of patients have lost the opportunity for surgery when tumors are discovered. This article mainly introduces the concept, development, pre-transformation evaluation and transformation therapy strategy of transformation therapy for unresectable liver cancer, aiming to provide reference for transformation therapy of unresectable liver cancer.

Secondary hyperoxalic nephropathy is a class of diseases that cause acute kidney disease or accelerate the progression of chronic kidney disease. Hyperoxaluria, renal tubular epithelial cell injury, hyperoxalemia and vascular endothelial cell injury are the main mechanisms of oxalate nephropathy. The incidence of secondary oxalate nephropathy may be underestimated and the prognosis may be poor due to the insufficient understanding of such diseases and the limitation of kidney biopsy samples. This article summarizes the pathogenesis, research status and treatment prospects of secondary oxalate nephropathy, provides reference for clinical work, and calls for clinicians to pay more attention to this kind of disease.

follicular lymphoma (FL) is a class of indolent lymphoma, but its heterogeneity is strong. Numerous studies have shown that the prognosis of FL is closely related to its tumor microenvironment, with T cell infiltration positively correlated with good prognosis, and the heterogeneity of T cell composition and localization in tumors (including CD8⁺PD-1⁺or FoxP3⁺etc.) are related to efficacy. Therefore, it is particularly important to better understand the specific effects of each treatment on FL T cells to reach their full antitumor potential. Lenalidomide has been reported to activate CD8⁺T cells, inhibiting regulatory T cells (Treg), restoring the formation of T cell immune synapses, and downregulating T cell PD-1 expression. However, how effective these properties are in FL patients remains unclear, especially in the context of binding to anti-CD20 antibodies. To investigate the efficacy of otuzumab in combination with lenalidomide in patients with FL, the GALEN trial (otuzumab in combination with lenalidomide in relapsed/refractory FL) was conducted. The study included 71 patients with FL (44 first-line treatment and 27 relapsed/refractory), and their cellular phenotype, transcriptome and function were analyzed before and after treatment, respectively. The results showed that lenalidomide upregulated PD-1 and increased HLA-DR expression in both cases. highlighted the role of lenalidomide in PD-1⁺Peculiar patterns of transcriptomic modifications induced in vivo by FL T cells. This functional assessment suggests that lenalidomide triggers T cell proliferation without eliminating Treg activity. Lenalidomide triggers transient transformation of T cells into proliferative effector memory T cells. Lenalidomide repairs T-cell immune synapses in FL patients, while octuzumab does not antagonize or even prolong this effect.

Rheumatoid arthritis (RA) is a systemic autoimmune disease characterized by chronic inflammation of the synovium of the joint. Compared with traditional drugs to improve rheumatism, glucocorticoids have the advantage of fast onset of action. Previous ACR and EULAR guidelines have recommended that low-dose glucocorticoids can be used as "bridge therapy" in the initiation treatment of RA. However, the use of glucocorticoids may bring side effects such as osteoporosis, inhibition of adrenal axis function and steroid diabetes to RA patients. Previous studies have shown that RA patients who continue to use low-dose prednisone can achieve better clinical efficacy, but there are currently no double-blind, randomized, placebo-controlled trials for specific low-dose prednisone reduction treatment regimens and continuous low-dose prednisone treatment regimens. The study used a multicenter randomized, double-blind trial to explore the clinical efficacy and safety of low-dose prednisone reduction versus continuous low-dose prednisone treatment in RA patients treated with tocilizumab. A total of 259 RA patients (including 200 women and 59 men) were enrolled in the study and randomized 1:1 to a continuous low-dose prednisone treatment group (oral prednisone 5 mg/d) and a reduced dose of prednisone treatment group (starting with prednisone 5 mg/d and reducing dose by 1 mg every 4 weeks). The mean change from baseline to week 24 in the DAS28 disease activity score in the prednisone taper group was 0.54 (95%CI: 0.35 to 0.73), whereas the mean change in DAS28 was-0.08 (95%CI: -0.27 to-0.12) [the difference between the two groups was 0.61 (95%CI：0.35~0.88），P<0.000 1］。 In addition, the incidence of RA disease activity (26% vs. 11%) and the probability of adverse events (5% vs. 3%) were lower in the sustained low-dose prednisone treatment group compared with the prednisone reduction group.