I. Surgical treatment of primary liver cancer
Surgical treatment of primary liver cancer includes hepatectomy and liver transplantation. The basic principles of hepatectomy include: ① thoroughness: the tumor is completely removed, and there is no tumor residue at the margin; ② Safety: Preserve normal liver tissue to the maximum extent, and reduce the operative mortality and the incidence of surgical complications. Liver function reserve should be evaluated before operation. Child-Pugh classification is usually used to evaluate liver parenchymal function, and CT and/or magnetic resonance imaging (MRI) are used to calculate the remaining liver volume.
hepatectomy
Classification of hepatectomy methods
Liver resection methods include radical resection and palliative resection. Radical resection means: ① the number of tumors does not exceed 2; ② No tumor thrombus in portal vein trunk and main branches, common hepatic duct and main branches, hepatic vein trunk and inferior vena cava; ③ There was no intrahepatic or extrahepatic metastasis, the tumor was completely removed by naked eyes, and there was no residual cancer at the margin; ④ No tumor residue was found in postoperative imaging examination, and the serum AFP of AFP positive patients before operation decreased to normal within 2 months after operation.
Indications of surgical treatment of liver cancer
With the development of modern liver surgery technology, tumor size is no longer the key limiting factor of surgery. Whether the tumor can be resected or not and the curative effect after resection are not only related to the size and quantity of the tumor, but also closely related to liver function, degree of cirrhosis, tumor location, tumor boundary, capsule integrity, venous tumor thrombus and so on.
Indications for liver cancer surgery issued by Hepatology Group of Chinese Surgical Association.
General condition (prerequisite): generally in good condition, no obvious organic diseases of heart, lung, kidney and other important organs; Liver function is normal, or only slightly damaged (Child-Pugh A grade), or liver function is classified as B grade, and it will return to A grade after short-term liver protection treatment; Liver reserve function (such as indocyanine green 15 minute retention rate (ICGR15)) is basically within the normal range; There were no resectable extrahepatic metastases.
The local focus of feasible radical hepatectomy must meet the following conditions: ① Single liver cancer, smooth surface, clear peripheral boundary or false capsule formation, liver tissue damaged by tumor: 30% but the tumor-free side of the liver is obviously enlarged, reaching more than 50% of the whole liver tissue; ② Multiple tumors and nodules
The local lesions of feasible palliative hepatectomy must meet the following conditions: ① 3 ~ 5 multiple tumors, which exceed the scope of semi-liver, should be subjected to multiple local resection; ② The tumor was confined to two or three adjacent hepatic segments or hemilivers, and the tumor-free liver tissue increased to more than 50% of the whole liver. ③ The tumor-free liver tissue of liver cancer in the central area of liver (middle lobe or segment ⅳ, ⅷ, ⅷ) increased significantly to more than 50% of the whole liver; ④ Patients with hilar lymph node metastasis should undergo lymph node dissection or postoperative treatment at the same time of tumor resection; ⑤ Patients whose peripheral organs have been invaded should be removed together.
Palliative hepatectomy also involves the following situations: liver cancer with portal vein tumor thrombus (PVTT) and/or vena cava tumor thrombus, liver cancer with cholangiocarcinoma thrombus, liver cancer with cirrhosis portal hypertension and resection of refractory liver cancer. Each case has its indications for surgical treatment (table 1). In addition, for liver cancer that is not suitable for palliative resection, palliative non-resection surgery should be considered, such as intraoperative hepatic artery ligation and/or hepatic artery and portal vein intubation chemotherapy.
The treatment of minor liver lesions deserves attention. Some minor lesions can not be found by imaging examination or intraoperative exploration, which leads to an increase in recurrence rate after hepatectomy. If incomplete resection is suspected, transcatheter arterial chemoembolization (TACE) is an ideal choice after operation, because besides the significance of treatment, there is also the significance of checking residual cancer. If there are residual cancer foci, remedial measures should be taken in time. In addition, the hepatitis virus load [HBV DNA/HCV RNA] should be checked in postoperative cases, and antiviral treatment should be given if indicated to reduce the possibility of recurrence of liver cancer.
Table 1 Indications of palliative hepatectomy for hepatocellular carcinoma
liver transplantation
Selection criteria of liver transplantation
At present, there are about 4000 cases of liver transplantation in China every year, among which the proportion of liver cancer patients is as high as 40%. In China, liver transplantation for liver cancer is only used as an auxiliary treatment for patients who can't be surgically removed, treated with radio frequency, microwave and TACE, and whose liver function can't be tolerated. Regarding the indications of liver transplantation, Milan standard and UCSF standard are mainly adopted internationally. However, there is no unified standard in China, and many units have put forward different standards, mainly including Shanghai Fudan standard, Hangzhou standard and Chengdu standard. These standards have the same requirements for non-invasion of great vessels, lymph node metastasis and extrahepatic metastasis, but they have different requirements for the size and number of tumors. China's standards expand the scope of indications for liver transplantation for liver cancer, which can benefit more patients with liver cancer, and may be more in line with China's national conditions and the actual situation of patients. However, it is necessary to form a relatively unified China standard based on high-level evidence-based medical evidence.
Prevention of recurrence after liver transplantation
It is generally believed that proper postoperative chemotherapy and antiviral therapy may reduce the recurrence of liver cancer and improve the survival time, but further research is needed.
Choice of liver transplantation and hepatectomy
Surgical treatment mainly includes hepatectomy and liver transplantation, and there is no uniform standard on how to choose. It is generally believed that for localized liver cancer, hepatectomy should be the first choice if the patient is not accompanied by cirrhosis; Liver transplantation should be the first choice if liver cirrhosis is complicated with decompensated liver function (Child-Pugh C grade) and meets the transplant conditions. It is still controversial whether liver transplantation can be performed for resectable localized liver cancer with good liver function compensation (Child-Pugh A grade). European experts support liver transplantation as the first choice, because the recurrence rate after hepatectomy is high, and the long-term survival rate and disease-free survival rate of liver transplantation patients who meet Milan standards are obviously better than those who have undergone hepatectomy. As far as a patient is concerned, it is emphasized to make a comprehensive evaluation and analysis according to the specific situation and make a surgical plan. In addition, for resectable liver cancer, preoperative angiography should be performed even if the imaging manifestations are localized resectable liver cancer, because it can find lesions that can not be found by other imaging methods, and can also determine whether there is vascular invasion.
2. Interventional treatment of primary liver cancer
Applicable people
1. Patients with unresectable advanced primary liver cancer (PLC);
2. Patients who can be surgically removed, but are unable or unwilling to undergo surgery for other reasons (such as old age and severe liver cirrhosis).
For these patients, radiation interventional therapy can be the first choice for non-surgical treatment.
Domestic clinical experience shows that radiation interventional therapy is effective for massive liver cancer and large liver cancer with relatively complete capsule. For resectable liver cancer, the influencing factors of prior surgical resection or interventional therapy include: ① serum AFP level; ② Whether the capsule of tumor focus is complete and the boundary is clear; ③ Whether there is tumor thrombus in portal vein.
Indications and contraindications
Both HAI and HAE have clear indications and contraindications (table 1). Chemoembolization (TACE) is very important, and it is not enough to simply give it to HAI.
Table 1 indications and contraindications of hepatic arterial chemotherapy (HAI) and hepatic arterial embolization (HAE)
Indications and contraindications
Hepatic arterial chemotherapy ● Primary or secondary liver cancer that has lost the opportunity of surgery.
Poor liver function or difficulty in using superselective intubation
Prophylactic hepatic arterial infusion chemotherapy for recurrent or postoperative hepatocellular carcinoma
Severe liver dysfunction
Massive ascites
Systematic failure
White blood cells and platelets decreased significantly.
Hepatic arterial embolization ● Before liver tumor resection, it can shrink the tumor and facilitate resection. At the same time, the number of lesions can be determined and metastasis can be controlled.
There was no serious liver and kidney dysfunction, no complete obstruction of portal vein trunk, and the tumor occupancy rate was less than 70%
Surgical failure or recurrence after resection
Control pain, bleeding and arteriovenous fistula
Prophylactic hepatic arterial chemotherapy after resection of hepatocellular carcinoma
embolism
Recurrence of hepatocellular carcinoma after liver transplantation
Severe liver dysfunction, belonging to Child-Pugh C grade.
Coagulation function is seriously impaired and cannot be corrected.
Portal hypertension, reversed blood flow, complete obstruction of portal vein trunk and few collateral vessels (liver function is basically normal, and tumor target vessels can be embolized by stages with superselective catheter technology)
Infection, such as liver abscess
Extensive metastasis has occurred in the whole body, and it is estimated that treatment can not prolong the survival time of patients.
Systematic failure
Cancer accounts for more than 70% of the whole liver (if the liver function is basically normal, a small amount of lipiodol can be used for embolization in stages)
Operating procedures and key points
1. Hepatic arteriography: Using Seldinger method, the catheter was placed in the celiac trunk or common hepatic artery for angiography. The acquisition of angiographic images should include arterial phase, solid phase and venous phase.
2. Perfusion chemotherapy: After carefully analyzing the angiographic manifestations and defining the location, size, number and blood supply arteries of the tumor, superselective intubation was performed into the blood supply arteries of the tumor for perfusion chemotherapy.
3. Hepatic artery embolization: It is necessary to choose a suitable embolic agent. Usually, ultra-liquefied lipiodol is fully mixed with chemotherapy drugs to form an emulsion. The dosage of lipiodol should be flexibly controlled according to the size of tumor, blood supply and the number of blood supply arteries of tumor. Superselective intubation must be used during embolization.
TACE for hepatocellular carcinoma emphasizes superselective intubation. In the past, only superselective intubation was emphasized for small hepatocellular carcinoma, but now superselective intubation is emphasized for all hepatocellular carcinoma except multiple nodules. For large hepatocellular carcinoma, superselective intubation is more conducive to controlling tumor growth and protecting normal liver tissue.
Follow-up and treatment interval
The follow-up period is usually 35 days to 3 months after interventional therapy, and in principle, the recovery from patients after interventional therapy lasts at least 3 weeks. The frequency of interventional therapy depends on the follow-up results: if the lipiodol deposition in the liver tumor focus is dense, the tumor tissue is necrotic, and there is no new focus or new progress within one month after interventional therapy, interventional therapy will not be carried out for the time being. The treatment interval should be extended as much as possible. The density can be increased in the first few treatments, and then the treatment interval can be extended without tumor progression to ensure the recovery of liver function. During the treatment interval, dynamic contrast-enhanced magnetic resonance imaging can be used to evaluate the survival of liver tumors, so as to decide whether it is necessary to intervene again.
"Individualization" Scheme Based on TACE
1. Two-stage resection of liver cancer after reduction: after interventional therapy for large liver cancer is significantly reduced, surgery can be performed.
2. Preventive interventional therapy after liver cancer surgery: Because most liver cancers occur on the basis of cirrhosis, most cases are multiple lesions, and some small lesions may not be found during surgery. For patients suspected of non-radical resection, it is suggested that preventive perfusion chemotherapy and embolization should be performed about 40 days after operation.
3. Treatment of portal vein tumor thrombus and inferior vena cava tumor thrombus: stent implantation and radiotherapy can be used. Regarding the tumor thrombus in inferior vena cava, if it is caused by tumor enlargement and compression, the patient has no symptoms, so we can only use TACE to observe whether the tumor can shrink. If the tumor thrombus is caused by tumor invading the inferior vena cava, it is suggested that the inferior vena cava stent should be placed at the same time as TACE treatment.
4. The individualized plan based on TACE also involves liver tumor rupture and bleeding, lung metastasis of liver cancer, TACE combined ablation, radiotherapy, gene and targeted therapy.
In a word, it should be emphasized that comprehensive treatment measures based on TACE should be taken actively to achieve good curative effect.
3. Ablation treatment of primary liver cancer
abstract
Ablation therapy refers to a treatment method that directly kills tumors locally under the guidance of imaging technology. At present, the most common methods are radiofrequency and microwave ablation and anhydrous alcohol injection. Ablation can be performed by percutaneous route, laparoscopic surgery or open surgery. The main means of image guidance are ultrasound and CT. Ultrasound-guided percutaneous ablation has obvious advantages such as minimally invasive, safe, simple, easy to repeat and relatively low cost. For patients with liver cirrhosis background and high recurrence tendency, PLC has high clinical compliance and has been widely used in China. At present, the standardized application of tumor ablation technology has gained international knowledge [see Radiology (2005 2005,235: 728-739)].
Indications and contraindications
Indications For patients with early liver cancer whose diameter is ≤5 cm or the maximum diameter is ≤3 cm and whose liver function is Child-Pugh A or B, besides surgery, radiofrequency or microwave ablation is the best choice. Small hepatocellular carcinoma with a single tumor diameter of ≤3 cm can be radically ablated, and alcohol ablation may also achieve the same goal. For small hepatocellular carcinoma without serious dysfunction of liver, kidney, heart, brain and other organs, with normal or nearly normal coagulation function, unwilling to undergo surgical treatment, small hepatocellular carcinoma with deep or central type, hepatocellular carcinoma that cannot be surgically removed due to various reasons such as recurrence or advanced cancer after surgery, patients with liver metastasis after chemotherapy, patients waiting for tumor growth control before liver transplantation, and patients with recurrence and metastasis after transplantation, ablation treatment can be adopted.
Due to the limitation of local treatment, it is not recommended to treat lesions larger than: 5 cm by ablation alone. The distance between the tumor and the common hepatic duct at the hilum and the left and right hepatic ducts should be at least 5 mm According to the liver function of patients with multiple lesions or large tumors, the combination therapy of TACE or TAE) and radio frequency before treatment is obviously better than the simple radio frequency therapy. For tumors located on the surface of the liver, adjacent to the cardiac diaphragm and gastrointestinal tract, open surgery or laparoscopic surgery can be selected, and radio frequency combined with absolute alcohol injection can also be used. In addition, TACE or other treatments after radiofrequency surgery may also improve the curative effect.
Contraindications ① are located in the dirty surface of the liver, including nude tumors above 1/3; ② Child-pugh grade C, TNM grade IV or tumor infiltration; ③ The liver is obviously atrophied and the tumor is too large, and the area to be ablated is1/3 of the liver volume; (4) recent esophageal (gastric fundus) varicose bleeding; ⑤ Diffuse hepatocellular carcinoma with tumor thrombus from main portal vein to secondary branch or hepatic vein tumor thrombus; ⑥ Severe functional failure of major organs; ⑦ Active infection, especially biliary inflammation; (8) Hematological diseases in which coagulation dysfunction cannot be corrected and the hemogram is seriously abnormal; Pet-name ruby intractable massive ascites; Attending disturbance of consciousness or cachexia.
Basic technical requirements
1. It is emphasized that the operation should be guided by imaging technology to ensure the safety, accuracy and effectiveness of treatment.
2. The ablation range should include 0.5 cm of adjacent tissues as far as possible to obtain a "safe edge" and completely kill the tumor. For invasive or metastatic cancer with unclear boundary and irregular shape, it is suggested that the safety range around the tumor should be expanded to above 1 cm if the adjacent liver tissue and structural conditions permit.
3. The standard method to evaluate the local curative effect is to use contrast-enhanced CT/ MRI or
Contrast-enhanced ultrasound to determine whether the tumor is complete or not
Complete response, CR). The lesions of CR showed no blood supply (that is, no enhancement). If the ablation is not complete, you can supplement the treatment immediately. If CR can't be obtained after three times of ablation, we should give up ablation treatment and switch to other treatment methods.
4. Follow-up should be conducted regularly after treatment to find possible local recurrent lesions and new liver lesions in time, and the advantages of percutaneous ablation, such as minimally invasive, safe, simple and easy to repeat, can effectively control tumor progress.
[Note: This * * * knowledge was jointly formulated by the Liver Cancer Committee of China Anti-Cancer Association (CSLC), the Clinical Tumor Collaboration Committee of China Anti-Cancer Association (CSCO) and the Hepatology Branch of Hepatology Branch of Chinese Medical Association. The fourth knowledge is shown in the B4 version on April 2nd. ]
Selection and application of common ablation methods
Radio frequency ablation (RFA) RFA is a widely used thermal ablation method. A large number of literatures and a number of randomized controlled clinical trials show that RFA has significant advantages over alcohol ablation in terms of high radical cure rate, less treatment times and high long-term survival rate for tumors of 3~5 cm. However, radiofrequency ablation has some problems, such as needle transfer and damage to surrounding organs caused by puncture and rupture of liver cancer, and it is not suitable for liver cancer located in the blind area of image.
Microwave ablation (MWA) MWA is also a commonly used thermal ablation method. Randomized and retrospective comparative studies show that there is no significant difference between MWA and RFA in local curative effect, complication rate and long-term survival. Now MWA technology can also inactivate tumors at one time. The establishment of temperature monitoring system can adjust the effective thermal field range and ensure the solidification effect. For tumors with rich blood supply, the main nourishing blood vessels of the tumor should be blocked first, and then the tumor should be inactivated, which can improve the curative effect.
Absolute alcohol injection (PEI) PEI is suitable for the treatment of small hepatocellular carcinoma with a diameter less than 3 cm and recurrent small hepatocellular carcinoma. It can also play a palliative role in liver cancer or recurrent lesions over 3 cm that are not suitable for surgery. Clinically, 0/0% ~ 25% of/kloc-lesions are close to tissues and organs such as hepatic portal, gallbladder and gastrointestinal tract, and thermal ablation treatment such as radio frequency or microwave may cause damage, so alcohol injection or combined thermal ablation can be performed on tumors in these parts to prevent complications.
Compared with other ablation methods, high intensity focused ultrasound ablation (HIFU) is a new non-invasive conformal therapy for tumor in vitro, with definite curative effect. The existing problems are: HIFU has a small focusing area and often needs to be repeated many times; Ultrasonic detection of tumor blind area; In the treatment, the irradiation channel is blocked by ribs, and even ribs need to be removed, which violates the original intention of minimally invasive surgery. Because the liver is affected by respiratory movement, it is difficult to locate it accurately. At present, it is considered that HIFU can not be used as a single treatment mode for primary liver cancer, and it can be considered as a supplementary treatment or palliative treatment after TACE.
Problems related to ablation and surgical treatment of small hepatocellular carcinoma
At present, there is controversy in academic circles about the first choice of surgical treatment or percutaneous ablation treatment for liver cancer below 5 cm.
A number of clinical prospective randomized controlled and retrospective comparative studies show that local ablation (mainly radio frequency and microwave) can achieve long-term survival effect similar to surgical resection. However, compared with the two methods, surgical resection has the advantages of rich experience, high popularization rate and low recurrence rate, while percutaneous local ablation has the advantages of low incidence of complications, rapid recovery and short hospitalization time. As far as the therapeutic effect is concerned, two randomized controlled studies show that there is no significant difference in survival rate between ablation therapy and surgical resection, but surgery has more advantages in DFS and recurrence rate.
Clinically, the appropriate initial treatment plan should be selected according to the comprehensive consideration of the patient's liver function and physique, the size, number and location of the tumor, the technical strength of our unit and the patient's wishes. Generally speaking, if the patient can tolerate anatomical hepatectomy, surgical resection should be the first choice, because it can remove the tiny metastases of the corresponding hepatic segment or lobe and effectively prevent postoperative recurrence. Most experts believe that surgical treatment is still the first choice for small liver cancer. For liver cancer ≤5 cm, which meets the indications of local surgical treatment and ablation treatment at the same time, surgical treatment is still carried out when conditions permit, and local ablation can be used as another treatment option besides surgical resection. For deep or central liver cancer ≤3 cm, local ablation can be preferred to achieve surgical resection effect and minimally invasive radical cure; For 3~5 cm liver cancer, choosing appropriate instruments and needles, mastering reasonable ablation technology and accumulating certain treatment experience can improve the treatment effect. In addition, liver transplantation also belongs to the category of surgical treatment, and the comparative data among ablation treatment, liver transplantation and anatomical hepatectomy are still lacking. Whether large hepatocellular carcinoma (> > 5 cm) can be ablated by multiple sites or stages, or by laparotomy or laparoscopy, there is no evidence-based medicine for reference at present and it is not recommended.
Both radiofrequency ablation and microwave ablation cause tumor cell necrosis through thermal effect. Microwave ablation may introduce more energy and the ablation range is relatively wider, but there is no significant difference in local curative effect, complications and survival rate between them. After ablation treatment, the necrosis of the focus should be observed regularly, and if there is any residual focus, it should be actively treated to improve the effect of ablation treatment.
Four. Radiotherapy for primary liver cancer
Radiotherapy is one of the basic methods to treat malignant tumors. However, before 1990s, patients with primary liver cancer (PLC) rarely received radiotherapy because of its poor effect and great damage to the liver. Since the mid-1990s, modern radiotherapy technologies such as three-dimensional conformal radiotherapy (3DCRT) and intensity modulated radiotherapy (IMRT) have gradually matured, providing new opportunities for the application of radiotherapy in the treatment of liver cancer. At present, three-dimensional conformal radiotherapy and IMRT for unresectable primary liver cancer have been published one after another. For patients with liver cancer confined to the liver, the 3-year survival rate of radiotherapy combined with interventional therapy has reached 25%~30%.
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Biological therapy and molecular targeted therapy of intransitive verbs
Biological therapy of primary liver cancer has been widely carried out at home and abroad, involving immunotherapy (cytokines, adoptive cellular immunity, monoclonal antibodies, tumor vaccines), gene therapy, endocrine therapy, stem cell therapy and many other aspects. At present, most biotherapy methods or technologies are still in the stage of research and development and clinical trials, and a few have been applied to clinic. Some single-center small-scale clinical trials show that biotherapy can improve the quality of life of patients and reduce the postoperative recurrence rate. Long-term use of interferon (INF)α as adjuvant therapy for patients with hepatitis B-related hepatocellular carcinoma (HCC) after radical operation can effectively delay recurrence, reduce recurrence rate and have antiviral effect. It is generally believed that proper application of thymosin α 1 and interleukin (IL)2 can enhance immune function, assist anti-virus and anti-tumor effects, help reduce postoperative recurrence and improve quality of life. Most of the reports of domestic scholars are the combined application of cytokines and other anti-tumor treatments. At present, the immunocompetent cells used for adoptive immunotherapy of liver cancer are mainly cytokine-induced killer (CIK) cells and specific killer cytotoxic T lymphocytes (CTL). CIK cells have a good effect on eliminating residual cancer, reducing anti-tumor side effects and improving quality of life. Radioimmune targeted therapy has certain effect. China The US Food and Drug Administration (SFDA) has approved iodine (13 1I)- metuximab injection for the treatment of liver cancer, but it is not recommended as routine treatment. Clinical trials of liver cancer vaccine and gene therapy are under way, among which dendritic cell (DC) vaccine has attracted much attention. Biochemotherapy and other comprehensive treatment models have shown good efficacy and tolerance, but there is no evidence of large-scale and multi-center collaborative research. Because it is difficult to carry out randomized controlled large-scale clinical trials and the evidence-based medicine is insufficient, biotherapy is not recommended as routine treatment, but it can be used as an adjuvant treatment or a treatment choice in inoperable situations.
7. Chinese medicine treatment
Among many malignant tumors in the body, liver cancer is one of the most common and effective tumors in TCM treatment. Traditional Chinese medicine (TCM) treats patients according to their overall characteristics, which is suitable for all types and stages of liver cancer. Some scholars have collected more than 100 kinds of prescriptions for treating liver cancer in China, and found that there are indeed patients whose tumors have improved or even disappeared after treatment with traditional Chinese medicine, but most of them are case reports, and there are too many schools of methods to be unified. Traditional Chinese medicine treatment should pay attention to the combination of attack and supplement as a whole, and adopt different treatment principles according to the different conditions of patients with liver cancer. Generally speaking, the advantage of Chinese medicine in treating liver cancer is that it is conducive to stabilizing the disease, with slight toxic and side effects and obvious improvement of symptoms, which slows down the development of the disease. A small number of patients with tumor shrinkage or long-term survival with tumor are easy for patients to accept and the cost is relatively low. At present, it is believed that Chinese medicine, as an auxiliary treatment for liver cancer, is helpful to reduce the toxicity of radiotherapy and chemotherapy, improve cancer-related symptoms, improve the quality of life and possibly prolong the survival period.
SFDA in China has approved and listed a number of modern Chinese medicine preparations in the national essential drugs list for the treatment of liver cancer, but the existing problems are poor standardization, poor repeatability and lack of high-level evidence-based medical evidence in the early stage. At present, a large-scale multicenter randomized controlled study on the treatment of liver cancer with traditional Chinese medicine preparations is underway, which is worth looking forward to.
Eight. Systemic chemotherapy
As early as 1950s, systemic chemotherapy was used to treat liver cancer. Most traditional chemotherapy drugs, including adriamycin, 5- fluorouracil, cisplatin and mitomycin, have been tried to treat liver cancer, but the efficiency of single drug is low (generally
At present, it is considered that systemic chemotherapy is superior to the best supportive treatment for patients with advanced liver cancer without contraindications, and it is still an optional treatment. Its main indications include: ① patients with advanced extrahepatic metastasis; ② Although it is a local lesion, it is not suitable for operation and transcatheter arterial chemoembolization (TACE); ③ Patients with portal vein tumor thrombus. The clinical research and application of a new generation of cytotoxic drugs challenge and question the traditional idea that liver cancer is not suitable for systematic chemotherapy. Some small sample studies and clinical observations suggest that this therapy can improve the objective and effective rate, control the development of the disease, relieve the symptoms, and may prolong the survival time, but it is urgently needed to be proved by large-scale randomized controlled multicenter clinical research, such as the international phase III clinical trial of combined chemotherapy based on oxaliplatin. Because PLC is more common in China, most patients have hepatitis B and liver cirrhosis background, the onset is hidden and the progress is rapid. At the time of diagnosis, many patients could not receive surgical resection or TACE treatment, and their survival time was short and their prognosis was poor. Therefore, it is necessary to actively explore a new high-efficiency and low-toxicity systemic chemotherapy scheme and its reasonable combination with molecular targeted drugs.
Nine. Concluding remarks
To sum up, liver cancer is a high-incidence tumor in China, and the treatment difficulties are as follows: ① Most patients have hepatitis B and liver cirrhosis background, often complicated with abnormal liver function; ② The onset age is relatively young, and it progresses rapidly, and it is prone to intrahepatic dissemination and distant metastasis; ③ Only some patients can receive surgical treatment, and the radical resection rate is low; ④ The postoperative recurrence rate is high. It is generally believed that the important factors affecting the curative effect include the size and number of tumors, the location and scope of tumor involvement, portal vein tumor thrombus and distant metastasis, the degree of liver function compensation and general situation. Therefore, we must attach importance to the early detection and diagnosis of liver cancer and emphasize the implementation of standardized comprehensive treatment. First of all, we should follow the basic principles of evidence-based medicine; Secondly, carry out extensive and in-depth multidisciplinary exchanges to formulate the best individualized treatment plan for patients with liver cancer to avoid improper or excessive treatment; Third, the basic research of tumor biology should be combined with clinical experience. In addition, the improvement of specialist medical access system and the training of professional doctors are also very important and necessary for the standardized diagnosis and treatment of liver cancer. Due to time constraints, the seminar failed to discuss and exchange some aspects of diagnosis and treatment of liver cancer, such as other methods of local ablation treatment of liver cancer, antiviral treatment of patients with liver cancer related to viral hepatitis and its complications, adjuvant treatment after resection, individualized treatment of comprehensive application of various treatment methods, etc., which need further discussion in the future.
After careful discussion on the practical experience and clinical research of liver cancer diagnosis and treatment, this knowledge was written by several experts. Although it has been revised repeatedly, it still has limitations. Therefore, it needs to be constantly supplemented and dynamically improved. It is necessary to draw lessons from international guidelines and the latest progress at home and abroad on the basis of the above-mentioned multidisciplinary expert knowledge, and formulate clinical guidelines for liver cancer according to the principles of evidence-based medicine, which will effectively promote the standardized treatment and research level of liver cancer and make positive contributions to the health of our people and all mankind.
China Anti-Cancer Association Liver Cancer Professional Committee (CSLC)
China Anti-cancer Association Clinical Cancer Cooperation Committee
Liver Cancer Group of Hepatology Branch of Chinese Medical Association
Main drafters: Yang Binghui, Cong, Yang,,, Jiang Guoliang, Zeng Zhaochong, Chen Minhua, Chen Minshan, Liang Ping, Lu Mingde, Luo Rongcheng, Liu Luming, Qin Shukui, Ye Shenglong, Ye Shenglong and Qin Shukui.
Comments by Wu, Tang Zhaoyou, Guan.
China medical forum (/yxztzx/lczn/200908/t20090801_15589 _ 4.html)