PDF(1688 KB)
PDF(1688 KB)
PDF(1688 KB)
肝血管瘤消融治疗适应证及技术要点
Indications and technical points of ablation therapy for hepatic hemangioma
肝血管瘤（HH）是临床常见的肝脏良性肿瘤，随着影像学、微创外科及消融技术的快速发展，HH 的诊治理念正由传统的经验化决策向规范化、个体化精准医疗路径转变。射频消融（RFA）与微波消融（MWA）等热消融技术具有创伤小、恢复快、住院时间短等显著优势，尤其在处理位于肝脏深部或毗邻重要血管、胆管的病灶时，能够最大程度保护正常肝实质。消融治疗HH的适应证需基于瘤体大小、生长趋势、临床症状及解剖位置进行综合评估。核心适应证包括：肿瘤长径≥5 cm且近2年有明显增大倾向（增加值>1 cm），或伴有持续性腹部疼痛、不适等相关症状；肿瘤位于肝实质内部，有合适的进针路径，周围无重要器官且凝血功能良好。在技术路径选择上，应依据病灶位置采用经皮穿刺、腹腔镜或开放方式，其中经皮穿刺是目前临床最常用的路径。针对长径≥10 cm 的巨大HH，应遵循“分次消融、安全优先”的原则，治疗目标在于有效控制症状和抑制瘤体生长，而非强求单次完全消融。采用RFA联合经导管动脉栓塞（TAE）或术中 Pringle 法血流阻断的多模态联合策略可显著提升消融效率。消融过程中需严密防治溶血相关并发症，通过围手术期充分水化、术中监测尿色及应用碳酸氢钠碱化尿液等措施预防急性肾损伤。术后评估主要依赖增强CT或MRI检查，以边缘无结节性强化作为完全消融的标志，并需建立长期的随访体系。随着3D实时导航及个体化方案的发展，HH的消融治疗将向更安全、精准的方向发展。
Hepatic hemangioma (HH) is a common benign liver tumor in clinical practice. With the rapid development of imaging, minimally invasive surgery, and ablation techniques, the concept of diagnosis and treatment for HH is transforming from traditional empirical decision-making to standardized and individualized precision medical pathways. Thermal ablation techniques, such as radiofrequency ablation (RFA) and microwave ablation (MWA), have significant advantages including minimal trauma, fast recovery, and short hospital stay. Especially when dealing with lesions located deep in the liver or adjacent to important blood vessels and bile ducts, they can maximize the preservation of normal liver parenchyma. The indications for ablation therapy of HH need to be comprehensively evaluated based on tumor size, growth trend, clinical symptoms, and anatomical location. Core indications include: a maximum tumor diameter ≥ 5 cm with a clear tendency to enlarge in the past 2 years (increase > 1 cm), or accompanied by related symptoms such as persistent abdominal pain and discomfort; The tumor is located within the liver parenchyma, has a suitable access route, is not surrounded by vital organs, and the patient has good coagulation function. Regarding the choice of technical approach, percutaneous, laparoscopic, or open approaches should be adopted according to the location of the lesion, among which the percutaneous approach is currently the most commonly used in clinical practice. For giant HH with a maximum diameter ≥ 10 cm, the principle of “fractionated ablation, safety first” should be followed, and the treatment goal is to effectively control symptoms and inhibit tumor growth, rather than insisting on complete ablation in a single session. A multimodal combined strategy using RFA combined with transcatheter arterial embolization (TAE) or intraoperative Pringle maneuver for blood flow occlusion can significantly improve ablation efficiency. During the ablation process, it is necessary to strictly prevent and treat hemolysis-related complications, and prevent acute kidney injury through measures such as adequate perioperative hydration, intraoperative monitoring of urine color, and application of sodium bicarbonate to alkalinize urine. Postoperative evaluation mainly relies on enhanced CT or MRI examination, using the absence of nodular enhancement at the margin as the sign of complete ablation, and a long-term follow-up system needs to be established. With the development of 3D real-time navigation and individualized protocols, ablation therapy for HH will evolve in a safer and more precise direction.
肝血管瘤 / 消融治疗 / 适应证 / 技术要点 / 射频消融 / 微波消融
hepatic hemangioma / ablation therapy / indications / technical points / radiofrequency ablation / microwave ablation
| [1] |
|
| [2] |
|
| [3] |
中国医师协会外科医师分会肝脏外科医师委员会, 中华肝胆外科杂志编辑委员会. 肝血管瘤热消融治疗专家共识(2021版)[J]. 中华肝胆外科杂志, 2021, 27(12):881-888.DOI:10.3760/cma.j.cn113884-20211108-00516.
|
| [4] |
国际肝胆胰协会中国分会肝血管瘤专业委员会. 肝血管瘤诊断和治疗多学科专家共识(2019版)[J]. 中国实用外科杂志, 2019, 39(8):761-765.DOI:10.19538/j.cjps.issn1005-2208.2019.08.01.
|
| [5] |
孙嘉鹏, 潘杰, 薛华丹, 等. 介入治疗成人肝血管瘤进展[J]. 中国介入影像与治疗学, 2024, 21(12):789-792.DOI:10.13929/j.issn.1672-8475.2024.12.020.
|
| [6] |
|
| [7] |
|
| [8] |
To report the complications of radiofrequency ablation (RFA) for hepatic hemangioma.
|
| [9] |
| [10] |
|
| [11] |
Few long-term data describe the natural history of hepatic hemangiomas. Because these lesions are frequently imaged repetitively on studies performed for other indications, health care professionals are commonly confronted with the problem of a growing hemangioma. Because the rate and magnitude of normal growth is not well characterized, it is difficult to recognize lesions growing at an abnormal rate, which may require further evaluation or intervention.To establish quantitatively the expected growth rate of hepatic hemangiomas and to define a measure of hemangioma growth that could be used clinically to help identify hemangiomas for which growth is more than expected.Retrospective cohort study at an academic hospital tertiary referral center evaluating the growth rate of hepatic hemangiomas on cross-sectional imaging studies during a 10-year period (1997-2007). The mean (SD) follow-up time was 3.7 (1.9) years. The radiology information system was searched in a 10-year period for hemangioma. Patients with hepatic hemangiomas that were 1 cm or larger as seen on cross-sectional imaging (computed tomography or magnetic resonance imaging), and 1 year or more apart were selected. Images with the longest interval between studies were selected for further review. Each study was rereviewed for diagnostic confirmation and to ensure consistency in measurement technique. Lesions were remeasured in 3 dimensions, and volumes were calculated using 3-dimensional software.Primary outcomes include the fraction of hepatic hemangiomas that demonstrated growth during long-term follow-up and the annual growth rate of those lesions.A total of 163 hemangiomas were identified in 123 patients. The mean (SD) initial size was 3.2 (3.1) cm. During follow-up, 39.3% of hemangiomas grew 5% or more in mean linear dimension. The mean (SD) annual linear growth rate was 0.03 (0.21) cm for all lesions and 0.19 (0.23) cm for those that grew 5% or more. By volume, 44.7% of lesions grew 5% or more. The mean (SD) annual volumetric growth rate was 2.8% (21.0%) for all lesions and 17.7% (22.8%) in those that grew 5% or more. The initial size predicted the growth in linear dimension and volume (P <.001). There was no significant change in growth rate over time, indicating uniform growth (R = 0.00843; P =.92).Nearly 40% of hepatic hemangiomas grow over time. Although the overall rate of growth is slow, hemangiomas that exhibit growth do so at a modest rate (2 mm/y in linear dimension and 17.4% per year in volume). Further research is needed to determine how patients with more rapidly growing hemangiomas should be treated.
|
| [12] |
Hepatic hemangiomas (HHs) are benign liver lesions often discovered incidentally on imaging for various unrelated pathologies. We herein review the etiology, classification, diagnostic imaging, and management of HHs.A comprehensive systematic review was performed utilizing MEDLINE/PubMed and Web of Science databases, with the end of search date being March 1, 2022, regarding HH diagnosis, imaging, and management.HHs can be broadly classified as capillary hemangiomas or cavernous hemangiomas. While the exact pathophysiology related to the development of HHs remains largely unknown, hormone exposure has been postulated to cause HH growth. HHs appear homogenously hyperechoic on US with distinct margins and posterior acoustic enhancement. While cavernous hemangiomas appear as well-defined hypodense lesions on pre-contrast CT images with the same density as the vasculature, one of the most reliable imaging features for diagnosing cavernous hemangiomas is high signal intensity on T2 weighted images. While most HHs are asymptomatic, some patients can present with pain or compressive symptoms with bleeding/rupture being very rare. Kasabach-Merritt syndrome is a rare but life-threatening condition associated with thrombocytopenia and microangiopathic hemolytic anemia. When HHs are symptomatic or in the setting of Kasabach Merritt syndrome, surgery is indicated. Enucleation is an attractive surgical option for HH as it spares normal liver tissue. Most patients experience symptom relief following surgical resection.HHs are very common benign liver lesions. High-quality imaging is imperative to distinguish HHs from other liver lesions. Surgery is generally reserved for patients who present with symptoms such as pain, obstruction, or rarely Kasabach-Merritt syndrome. Surgery can involve either formal resection or, in most instances, simple enucleation. Patients generally have good outcomes following surgery with resolution of their symptoms.© 2022. The Society for Surgery of the Alimentary Tract.
|
| [13] |
There is currently a lack of consensus regarding the clinical features, diagnosis, treatment indications and options, and risk assessment of hepatic hemangioma patients.This was a multicenter, real-world study that analyzed a large number of hepatic hemangioma cases in China and included patient data on epidemiology, diagnosis, treatment methods, and outcomes.A total of 5,143 patients hospitalized for hepatic hemangioma were included, of whom 34.42% were male and 65.58% were female. The age distribution was concentrated between 30 and 60 years old, accounting for 87.41% of the patients. Among the hepatic hemangioma patients, 60.8% had only one tumor, with the most common pathological type being cavernous hemangioma (96.07% of cases). The treatment motivations and indications included anxiety, obvious clinical symptoms, rapid tumor growth, unclear diagnoses and acute emergencies. Overall, 41.4% of the patients were treated for psychological reasons, while 30.59% were treated because they presented obvious (primarily nonspecific) clinical symptoms. Hepatic resection was the main therapeutic method and was based on various indications. There were a small number of patients with Kasabach-Merritt syndrome, according to its generally recognized definition.Most patients in this study who were hospitalized for hepatic hemangioma did not meet the indications for requiring treatment. Surveillance is the recommended course of action for definitively diagnosed hepatic hemangioma, and a new classification system is needed to standardize the diagnosis of this condition.2021 Annals of Translational Medicine. All rights reserved.
|
| [14] |
|
| [15] |
Thermal ablation by use of radiofrequency energy can be used to achieve necrosis of liver tumours, and increased availability of this technique is leading to more widespread use. Much of the impetus for the use of radiofrequency ablation has come from cohort series that have provided an evidence base for this technique. Here, we give an overview of the current status of radiofrequency ablation for liver tumours, including its physical properties, to assess the characteristics that make this technique applicable in clinical practice. We review the technical development of probe design and summarise current indications and outcomes of reported clinical use. We also provide a profile of side-effects and information on the integration of this technique into the general management of patients with liver tumours. Current evidence suggests that radiofrequency ablation can be done with few side effects; however, although this technique seems to ablate tumours effectively, it should form part of multidisciplinary care for liver cancer. Crucially, the role of radiofrequency ablation in lengthening the survival of patients with liver tumours remains to be assessed.
|
| [16] |
|
| [17] |
|
| [18] |
|
| [19] |
Percutaneous ablation under imaging guidance is a curative treatment that can induce complete tumor necrosis with advantages of minimal invasiveness and a low risk of complications. Thermal ablation, which includes radiofrequency ablation and microwave ablation, is a representative technique that has sufficient antitumor effects in cases of hepatocellular carcinoma with ≤3 lesions measuring ≤3 cm and preserved liver function. The short- and long-term outcomes of patients are comparable with those achieved with surgical resection. Despite their nonmalignant nature, some benign liver tumors require treatment for symptoms caused by the presence of the tumor and/or continuous enlargement. Ablation may be the treatment of choice because it has lower burden on patients than surgical treatment. This review describes the recent concepts, progress, and limitations of ablation-based treatment for benign liver tumors.© 2023 Authors.
|
| [20] |
中国医师协会外科医师分会, 中国研究型医院学会肿瘤介入专业委员会. 肝血管瘤射频消融治疗(国内)专家共识[J]. 临床肝胆病杂志, 2017, 33(9): 1638-1645. DOI: 10.3969/j.issn.1001-5256.2017.09.006.
|
| [21] |
Percutaneous microwave ablation of liver tumours is a well-established technique that has been proven to be effective in the curative and palliative treatment of small volume primary and secondary liver tumours. Microwave ablation is designed to achieve larger areas of necrosis compared to radiofrequency ablation and has a good safety profile among liver tumour treatments. Mortality is unreported and major complications are rare. Knowledge of potential complications is essential for interventional radiologists performing liver ablation in order to reduce patient morbidity. The aim of this review is to illustrate major complications post microwave ablation in a pictorial format as well as a discussion on how best to avoid these complications
|
| [22] |
|
| [23] |
To evaluate the efficacy, safety and feasibility of microwave ablation (MWA) for large (5–10 cm in diameter) hepatic hemangioma.
|
| [24] |
|
| [25] |
Hepatic hemangioma is the most common benign liver tumor. This study aims to evaluate the feasibility, safety and efficacy of Trans-arterial embolization (TAE) combined with thermal ablation in the treatment of large hepatic hemangioma (> 5 cm).From January 2018 to December 2021, 82 patients and 112 large HH with a maximum mean diameter of 8.24 ± 0.26 cm (range: 4.3-16.0 cm) and a cumulative diameter of 9.45 ± 0.45 cm (range:5.0-29.6 cm) were treated with laparoscopic-assisted and ultrasound (US)-guided percutaneous radiofrequency ablation (RFA) or microwave ablation (MWA) during a single general anesthesia episode following TAE. After surgery, therapeutic efficacy was assessed by contrast-enhanced imagings during follow-up. Median follow-up time was 14 months (range: 2-48 months).All patients have a mean operating time of 79.10 ± 2.59 min. The plain CT revealed that 112 treated lesions were totally covered (100%). Hemoglobinuria was detected in 28 patients (34.1%), and there were no cases of acute renal failure. Abdominal pain occurred in 40 patients (48.8%), while peritoneal effusion in six (7.3%). Acute cholecystitis developed in 11 patients (13.4%), constipation in five (6.1%), and nausea and vomiting in 14 (17.1%). According to the Clavien-Dindo classification, 54 patients (65.9%) had minor complications, while none had severe complications. The follow-up, no Hepatic hemangioma growth was observed.Preoperative TAE combined with thermal ablation is a novel therapeutic strategy for large HH. This strategy is simple, less risky, and feasible.© 2025. The Author(s).
|
| [26] |
|
| [27] |
|
| [28] |
|
| [29] |
Hepatic hemangioma is the most common benign solid lesion of the liver. Contrast-enhanced computed tomography or magnetic resonance imaging is recommended for definitive diagnosis of hepatic hemangioma. However, these modalities have drawbacks in terms of radiation exposure, invasiveness, and high cost for examination. “Fluttering sign” is one of the candidate findings considered specific for hepatic hemangioma that can be useful for diagnosis of hepatic hemangioma using grayscale US alone. However, the assessment is subjective and the findings are weak and likely to be overlooked in some cases. We developed a software program, Fluctuational Imaging, for objective detection and depiction of “fluttering sign”. Here, we evaluated the ability of Fluctuational Imaging software to depict “fluttering sign” in hepatic hemangioma. Presence or absence of “fluttering sign” was evaluated in the grayscale US videos and Fluctuational Imaging software analysis results of patients with hepatic hemangioma. The Cohen’s kappa test showed very good agreement (0.95). Fluctuational Imaging software can detect and depict the phenomenon of “fluttering sign” well and may be a useful tool for diagnosis of hepatic hemangioma.
|
| [30] |
|
| [31] |
The aim of this retrospective study was to compare the feasibility and efficiency of ultrasound-guided percutaneous microwave ablation (US-PMWA) assisted by three-dimensional visualization ablation planning system (3DVAPS) and conventional 2D planning for hepatocellular carcinoma (HCC) (diameter > 3 cm).
|
| [32] |
|
利益冲突 所有作者均声明不存在利益冲突
/
| 〈 |
|
〉 |
