内科学-肝癌-叶胜龙 1

PrimaryLiverCancer,LiverCancerInstituteZhongshanHospitalFudanUniversity,Definition,MalignanttumorsfromHepatocytesandintrehepaticcholangiocytes“KingofCancer”-Short-termsurvivalperiod（3-6m）Highincidenceatage40-50y,EpidemiologyEtiologyormultipletumorsnonemorethan5cmT3Multipletumorsmorethan5cm；ortumorinvolvingabranchoftheportalorhepaticveinT4TumorwithdirectinvasionofadjacentorgansotherthanthegallbladderorwithperforationofvisceralperitoneumN0NoregionallymphnodemetastasisN1RegionallymphnodemetastasisM0NodistantmetastasisM1Distantmetastasis,TNMStaging,StageT1N0M0StageT2N0M0StageAT3N0M0StageBT4N0M0StageCT1-4N1M0StageT1-4N0-1M1,我国原发性肝癌分期标准,分期肿瘤癌栓淋巴结转移Child-Pugha单个，3cm无无无Ab半肝1-2个,5cm无无无Aa半肝1-2个,10cm无无无A两半肝2个,5cm无无无Ab半肝12个,10cm无无无A两半肝2个,5cm无无无A任意门V分支、肝V或胆管无无A任意无无无Ba任意门V主干或下腔V有或无有或无A或B任意有或无有有或无A或B任意有或无有或无有A或Bb任意有或无有或无有或无C,EpidemiologyEtiology&PathogenesisPathologyClinicalManifestationClinicalStagingDiagnosisTreatmentPrevention,Diagnosis,MarkersAFPAFP-L3DCPGGT-AFU,ImagingUltrasonography(US)Computertomography(CT)Magneticresonanceimaging(MRI)AngiographyScintigraphy,DiagnosisTumormarkers,甲胎蛋白(alpha-fetoprotein,AFP)Normal：25%良性肝病0.75门静脉癌栓,ImagingDiagnosisUltrasonography(US),ImagingDiagnosisCT,Evaluation：明确病灶的部位、数目、大小、血管关系提示病变性质，增强扫描有助鉴别放射治疗定位了解肝周组织受累情况,ImagingDiagnosisCT,平扫：多为不均匀低密度病灶增强扫描：动脉期呈高密度增强，门脉期低密度病灶对比更明显，可见门脉癌栓,ImagingDiagnosisCT,ImagingDiagnosisMRI,能获得三维图象软组织分辨率高无放射线损伤显示肝内外胆管和血管,ImagingDiagnosisMRI,T1加权象病灶呈高低混合区T2加权象呈不规则、不均匀高信号病灶周围可见线条状低信号影(“假包膜”)肝内外血管受侵犯，癌栓表现为T1中强度信号、T2高强度信号,ImagingDiagnosisMRI,T1WI,T2WI,T1加权,增强动脉期,增强静脉期,ImagingDiagnosisScintigraphy,肝脏平面显象胶体99mTc单光子计算机断层显象(SPECT)阳性显象67Ga，99mTc-PMT肝血池显象99mTc-RBC,ImagingDiagnosisAngiography,明确肝占位病变(400g/L，能排除活动性肝病、妊娠、生殖系胚胎源性肿瘤及转移性肝癌，并能触及坚硬肿块的肝脏或影像学检查有明确的肝癌特征性占位性病变者。2AFP400g/L，能排除活动性肝病、妊娠、生殖系胚胎源性肿瘤及转移性肝癌，并有两种影像学检查具有肝癌特征性占位病变或有两种肝癌标志物（AFP异质体、异常PTT、GGT-、AFU等）阳性及一种影像学检查具有肝癌特征性占位性病变者。3有肝癌的临床表现，并有肯定的肝外转移病灶（包括肉眼可见的血性腹水或在其中发现癌细胞）并能排除转移性肝癌者。,DiagnosticProcedure,AFP-L3BiopsyPathologicalDiagnosisHisLiverAFPUltrasoundClinicalDiagnosisSignfunctionOthermarkersCT/MRIIsotopeAngiography,DifferentialDiagnosisAFPPositive,无占位：妊娠睾丸或卵巢肿瘤活动性肝病：AFP与ALT绝对值和动态变化有占位：少数转移癌（胃、胰腺）,DifferentialDiagnosisAFPNegative,OccupiedUltrahepaticIntrahepaticLiquid（Cyst,Abscess）SolidBenign（Hemangioma）MalignantMetastaticcancerPrimaryCholangiocarcinomaHepatocellularcarcinoma,ActiveLiverDiseases,AFP多在400g/L以下AFP动态变化与ALT波动相关AFP异质体LCA结合型25%定位诊断（）或为硬化结节,LiverCyst,多无症状，无肝病背景多合并肾囊肿，常有家族性B超表现为液性暗区CT增强扫描无造影剂填充,LiverAbscess,可有感染史，多有炎症表现（发热、肝区叩痛、血象增高）B超及CT呈液性暗区，四周有较厚炎症反应区肝穿刺抽吸可获脓液,Hemangioma,无症状，多无肝病背景，肝硬化不明显小病灶超声多呈高回声，RI0.5CT增强扫描造影剂由外周向中心填充并滞留核素血池扫描（）,Hemangioma,B超,CO2造影,MetastaticLiverCancer,原发灶多来自胃肠道多无肝病背景超声及CT可见肝内大小相仿多数结节CEA、CA19-9多为阳性,EpidemiologyEtiology&PathogenesisPathologyClinicalManifestationClinicalStagingDiagnosisTreatmentPrevention,KeyFactorsforTreatment,TumorSizeandNumberTumorInvolvementAreaTumorEmboliofMainPortalVeinLiverCompensation,SurgicalTreatment,HepatectomyNonresectionLigationCatheterizationCryotherapyTransplantation,SurgicalTreatment,Hepatectomy全身情况好，无严重心、肺、肾功能障碍肝功能代偿（ALT,SB,A/G,GGT,PTT）无腹水、肢肿或远处转移病变局限于一叶或半肝，未累及门静脉主干和下腔静脉,SurgicalResection,切除治疗原则合并肝硬化的小肝癌，以局部切除为主肿瘤包膜完整者倾向于局部切除左叶肿瘤尽可能规则性切除，右叶肿瘤一般作部分切除亚临床复发和单个转移可再手术切除非切除姑息外科优于明显残癌的姑息切除,SurgicalTreatment,ArterialLigation(Embolization)/Catheterization手术探查证实肿瘤不能切除（肝内多发、肿瘤巨大紧贴肝门、破裂出血难以控制）切后残癌，复发可能大大肝癌二期切除准备无黄疸腹水，肝功能基本代偿（ALT50%）无其他主要脏器严重病变,SurgicalTreatmentCryotherapy,严重肝硬化，不能耐受手术切除肿瘤紧靠大血管，不宜手术切除主瘤切后残留结节不能再切除的复发癌切前应用预防术后复发,SurgicalTreatmentLivertransplantation,适应证：小肝癌合并严重肝硬化，50岁以下，无活动性肝病，无黄疸、腹水、远处或腹腔内广泛转移，无下腔静脉癌栓，无心、肺、肾严重疾患，无感染病灶或糖尿病存在问题：脑死亡供体，费用，疗效,Non-surgicalTreatment,InterventionalRadiology-TACELocalAblationRadiotherapyChemotherapyBiotherapyTraditionalChineseMedicine,Non-surgicalTreatmentTransarterialChemoembolization（TACE）,不能切除的肝癌：右叶为主或较大、多发肿瘤切除术前缩小肿瘤，有助根治切除术后消灭残癌减少复发肝癌破裂紧急止血复发肝癌无法切除减轻症状，控制疼痛、出血及动静脉瘘,TACE,Non-surgicalTreatment-LocalAblation,Percutaneousethanolinjection(PEI)Radiofrequencyablation(RFA)Microwavecoagulationtherapy(MWCT)High-intensityfocusedultrasound(HIFU)Argon-heliumtargetingcryotherapy,LocalAblationPercutaneousEthanolInjection（PEI）,Indication肝功能基本正常肿瘤结节直径小于3cm肿瘤结节总数不超过3个,PEI,小肝癌与手术治疗疗效相似对肝功能影响小并发症少，易耐受纤维间隔难以均匀弥散局部复发率高反复多次注射，增加针道转移危险,RadiofrequencyAblation(RFA),射频电流使组织和细胞脱水、离子振荡产生高热（70-110)，凝固坏死主要用于治疗小肝癌多弹头射频和外套针冷却可提高疗效,RFAforSmallHCC,WangZS,MaoYY,RFAforSmallHCC,Radiotherapy,Indication全身状况较好，肝功能基本正常肿瘤较局限（主要位于右叶），10y-363cases(Follow-upby2006),U.S.survivors(1905-1970)5y-45cases(Curutchet,1971),EpidemiologyEtiology&PathogenesisPathologyClinicalManifestationClinicalStagingDiagnosisTreatmentPrevention,PrimaryPreventionofHCC,Waterreformpreventwaterpollution,improvewaterqualityFoodcontrolalterationoffoodformation,foodcustody,moldspreventionanddetoxicationHepatitisPreventionpreventionandcureofhepatitisandcirrhosis，decreasemodeoftransmission(injectionandtransfusion),HepatitisBvaccinationChemoprophylaxisseleniumsupply，decreaseofnitrosamineintakeandsmoking,SecondaryPreventionofHCC,Earlydetection,diagnosis&treatmentConsistantinfectionofhepatitisvirusesisamaincauseofdevelopingprimarylivercancerHigh-riskpopulation：Male35y(Female45y),HBV(+)orHCV(+)orcirrhosis,FamilyhistoryRoutinescreening：AFPultrasonographytwiceperyear,ResultofScreeningHCC,OtherScreeningResultsinChina,ScreeningNo.MethodHCCNo.IncidenceSubclinical(per100000)NativePopulationShanghai(71-76)1967511