肝癌的局部治疗.ppt

肝癌局部治疗 内容提要Image guidedpercutaneousablationisestablishedasthebesttherapeuticchoiceforpatientswithearly stageHCCwhensurgicalresectionorlivertransplantationareprecluded 影像介导的经皮消融术是无法进行手术和肝移植的病人最佳的治疗方法 TACEisthestandardofcareforpatientswithintermediate stagedisease 经肝动脉化疗栓塞 TACE 是中期肝癌患者的标准治疗方法 TheBarcelonaClinicLiverCancer BCLC classificationhasemergedinrecentyearsasthestandardclassificationthatisusedforclinicalmanagementofpatientswithHCC 目前BCLC分类是肝癌患者临床分期的标准方法 Very Early StageHCC超早期肝癌Invery early stageHCC thepresenceofasolitarysmallnodule smallerthan2cmindiameter inpatientswithChild PughclassAdisease theabsenceofmicrovascularinvasionanddisseminationofferthehighestlikelihoodofcure 超早期肝癌直径小于2cm Child Pugh评分A 无血管侵犯和远处转移 最有可能被治愈 AccordingtotheBCLCstagingsystem thesepatientscanbeofferedsurgicalresectioniftheyarenoncirrhoticoriftheyhavecirrhosisbutstillhavewell preservedliverfunction normalbilirubinlevel andanabsenceofclinicallysignificantportalhypertension Suchpatientswillnotdecompensateafterresectionandhavea5 yearsurvivalrateofbetterthan75 对BCLC分类中的超早期肝癌 如果没有肝硬化 或虽然有肝硬化但肝功能尚可 胆红素水平正常 没有明显门脉高压 则可以考虑手术切除 这类病人术后不会引发代谢失常 5年生存率大于75 Anatomicresection definedastheenblocremovalofaportionofliversuppliedbyamajorbranchoftheportalveinandthehepaticartery isconsideredthepreferredsurgicaltechnique becauseittheoreticallyallowstheeradicationofintrahepaticmetastasesofHCC resultinginabetteroutcomeascomparedwithnonanatomicresection 解剖切除 指整块切除由门脉及肝动脉主要分支供血的肝组织 被认为是更好的手术方式 因为其理论上可将潜在肝内转移灶一起切除 However severeimpairmentofliverfunctionand possibly liverfailure couldfollowsurgicalintervention 但过多切除肝组织可能造成肝功能不全 甚至肝衰竭 对于超早期肝癌 手术和消融效果类似 但适用于不同病人RFablation small 2cm centrallylocated消融适合于小 位置深的病灶resection subcapsularorperivascularlocation adjacenttothegallbladder手术适合于邻近包膜 血管或胆囊窝的病灶 这些地方消融并发症高 病灶清除不干净 超早期肝癌患者接受射频消融治疗前 动脉期明显强化 a 门脉期呈相对低密度 并见假包膜 b 治疗后 cd 肿块无强化 范围较前扩大 Early stageHCC早期肝癌Early stagediseaseincludespatientswithpreservedliverfunction Child PughAandB withsolitaryHCCoruptothreenoduleslessthan3cminsize 早期肝癌指肝功能尚存 Child PughA和B 单个结节 或三个结节以内范围小于3cm Thesepatientscanbeeffectivelytreatedwithresection livertransplantation orpercutaneousablation withthepossibilityoflong termcureand5 yearsurvivalrateestimatesrangingfrom50 to75 这类病人的治疗主要包括手术 消融和肝移植 5年生存率约50 70 对早期肝癌 手术切除治疗效果似乎比射频消融更好 但还需更进一步证据 Amongdifferentablativetechniques RFablationiscurrentlyconsideredtobethebesttreatmentoptioninpatientswithearly stageHCC 在不同消融方法中 射频消融被认为是最有效的 AcombinationofTACEfollowedbyRFablationhasbeenusedtominimizeheatlossduetoperfusionmediatedtissuecoolingandtoincreasethetherapeuticeffectofRFablation 射频消融前先进行肝动脉化疗栓塞比单纯射频消融更有效 射频消融过程中如果破坏血管 外溢的血液可使局部环境冷却 减少对肿瘤细胞的杀伤 而肝动脉化疗栓塞可事先栓塞血管 从而随后的射频消融更有效 Patientswithasolitarylarge 5cm tumordeservespecialmention Evenifthesepatientscannotbeconsideredtohaveearly stagediseasebecausetheydonotqualifyfortransplantation noupperlimitofsizeforsurgicalresectionappearsintheBCLCflowchart andthesepatientsshouldnotbeexcludedfromsurgicalreferralbecausetheirtumorsaretoolarge Differentablativemodalitiesdonotcurrentlyprovidesufficientvolumeofablationtosuccessfullytreatthesetumors andtheresultsoftransarterialtherapiesasstandalonetreatmentsarehighlyvariableinthisclinicalscenario 对单发大于5cm肿块 因为肿块体积太大 已不适合肝移植 但根据BCLC分类方法 这些病人仍能进行手术切除 消融术很难完整破坏肿瘤 而动脉栓塞等治疗的效果则很不确定 ForpatientswithHCCwhoareonthewaitinglistforlivertransplantation BothablationandTACEcanbeappliedatthetimeoflisting 对于等待肝移植的病人 消融和TACE都可以考虑 其他消融方法 有效性有待进一步证实 Microwave MW ablation微波消融ElectromagneticMWsheatmatterbyagitatingwatermoleculesinthesurroundingtissue whichproducesfrictionandheat thusinducingcellulardeathbymeansofcoagulationnecrosis 微波消融利用微波扰乱周围环境水分子 制造摩擦和热量 导致细胞凝固性坏死 ThemainfeaturesofMWtechnology whencomparedwithexistingthermalablationtechnologies includeconsistentlyhigherintratumoraltemperatures largertumorablationvolumes fasterablationtimes andanimprovedconvectionprofile 和其他消融术相比 微波消融温度更高 时间更短 能用于治疗更大体积肿瘤 Asaresult theadvantageofMWoverRFablationisthattreatmentoutcomeislessaffectedbyvesselsinproximitytothetumor 和射频消融比 微波消融较少受肿瘤血供影响 irreversibleelectroporation IRE 不可逆电穿孔IREisamethodtoinduceirreversibledisruptionofcellmembraneintegritybychangingthetransmembranepotential resultingincelldeathwithouttheneedforadditionalpharmacologicinjury IRE造成膜电位不可以改变 导致细胞死亡IREcreatesasharpboundarybetweenthetreatedanduntreatedareasinvivo 实验证实IRE可制造锐利边缘Moreover becauseIREisanonthermaltechnique issuesassociatedwithperfusion mediatedtissuecoolingorheatingarenotrelevant 因为IRE不通过产热起作用 所以治疗效果与肿瘤血供无关 早期肝癌患者接受射频消融治疗前 动脉期明显强化 a 门脉期呈相对低密度 并见假包膜 b 治疗后 cd 肿块无强化 范围较前扩大 CombinedRFablationandTACEwithdrug elutingbeadstotreatearly stageHCCina71 year oldmanwithhepatitisC relatedlivercirrhosis a PretreatmentarterialphaseT1 weightedgradient echomagneticresonance MR imageshowshypervascularHCCatdomeofliver b d CTimagesobtainedimmediatelyafterRFablationshowresidualviabletumor b c superiorandlateraltoablationzone arrow while d necrosiswithoutevidenceofresidualviabletumorisseeninferiorly e f Angiogramsshowtreatmentcompletionwithintraarterialinjectionof2mLof100 300 mmdrug elutingbeadsloadedwith50mgofdoxorubicin DCBeads BTG Biocompatibles Farnham England Arrow residualviabletumor g i CTimagesobtained1monthaftertreatmentshowcompleteresponse 射频消融联合肝动脉化疗栓塞 化疗药物缓释颗粒治疗早期肝癌射频消融后少数肿瘤残留 箭 进一步行肝动脉化疗栓塞 化疗药物缓释颗粒治疗后肿瘤完全清除 Intermediate StageHCC中期肝癌Patientswithintermediate stageHCC ie multinodularHCC relativelypreservedliverfunction absenceofcancer relatedsymptoms andnoevidenceofvascularinvasionorextrahepaticspreadareconsideredcandidatesforTACE 中期肝癌 多结节性 肝功能尚存 无副癌综合症 无血管侵犯及肝外转移 患者的治疗主要为肝动脉化疗栓塞 TACE AlthoughTACEimprovessurvivalforpatientswithintermediate stageHCCasawhole notallsuchpatientswillderivesimilarbenefitfromTACEandthatsomemaybenefitfromtreatmentsotherthanTACE 虽然总体上TACE可提高中期肝癌患者的生存率 但对不同病情的患者效果各异 有时需要考虑其他更好的治疗方法 TheriskofTACE associatedcomplicationsmaybegreaterinpatientswithmoreextensivediseaserequiringnonselectiveembolization withunfavorablevascularanatomy andwithpoorresidualliverfunction TACEisnotsuitable ingeneral forpatientswithdecompensatedlivercirrhosis definedasChild PughB score 8 withascitesand orjaundice owingtothehighriskofserioustreatment relatedcomplications TACE治疗存在风险 对于严重病例常需广泛栓塞 这可能破坏过多肝组织 导致肝功能无法代偿 并可能导致严重并发症 失代偿型肝硬化 Child PughB 评分 8 腹水 黄疸 和血管解剖异常等因素也影响治疗效果 其他方法 TACEwithdrug elutingbeads TACE 化疗药缓释颗粒systemictherapywithatargetedagent 全身靶向药物治疗Radioembolization intraarteriallyinjectedmicrospherescoatedwithyttrium90 90Y 放疗性栓塞 经肝动脉注入包被90Y 放射原 的微球体 Advanced StageHCC晚期肝癌Patientswithadvanced stageHCCincludethosewhopresentwithcancersymptomsand orvascularinvasionorextrahepaticspread Overall thesepatientshaveashorterlifeexpectancy 50 survivalat1year 晚期肝癌 有症状 血管侵犯 肝外转移 患者1年生存率约50 AccordingtotheBCLCtreatmentstrategy systemictherapywiththemultikinaseinhibitorsorafenibisconsideredthetherapyofchoiceforpatientswithadvancedHCC BCLC建议对晚期肝癌患者施行索拉非尼 激酶抑制剂 可抑制血管生成和细胞增殖 全身化疗 Itisdebatableifpatientsclassifiedashavingadvancedstagediseasewhohavemildlyimpairedperformancestatusbutwithuninodularormultinodulardiseasewithoutvascularinvasionandextrah