原发性肝癌教案

内 容教具及时间分配第三十六章 肝脏疾病第2节 原发性肝癌引言（通过比较傅彪和金素梅不同的治疗结果强调肝癌诊治的核心要求是早期诊断） 相同点就诊原因当时病情治疗结果傅乙肝病史肝区疼痛难忍晚期肝癌1年死亡金定期体检发现小肝癌99年至今Primary Liver Cancer本堂课的内容提要。 一、发病率和死亡率（Incidence and mortality）1. 亚、非、拉丁美洲发病率升高；欧洲发病率下降。全球每年150万人死于原发性肝癌2. 原发性肝癌是我国常见恶性肿瘤，是继胃癌、食管癌后排第三位 3. 男女比例 4：14. 中年人占905. 中国有30万新发肝癌病例，其中能够住院手术的不到10，其余90的病人，诊断时就是晚期了。二、病因 (Etiology)病因：目前尚不清楚，可能与以下因素有关。1 病毒性肝炎，肝硬化：乙、丙和丁型肝炎与肝癌有关，90%肝癌患者有乙肝感染背景。70%原发性肝癌在肝硬变基础上发生2 黄曲霉毒素：食物黄曲霉毒素含量和粪便排出量与肝癌死亡率成正相关，在动物中能以黄曲霉毒素复制肝癌模型。3 环境因素：水污染，硝酸盐和亚硝胺，缺硒。三 病理（Pathology）大体病理分型： 1 块状型：直径10cm为巨块型，合并肝硬化程度轻2 结节型：直径200ng/ml ，持续2月以上，并排除妊娠、活动性肝病、生殖腺胚胎肿瘤者。 意义： 诊断原发性肝癌的高度特异性指标 用于鉴别肝癌与活动性肝病 用于肝癌的普查 观察手术效果和早期发现肿瘤的复发和转移4B超检查：低密度灶、周围伴声晕。 一线检查方法。5 CT：平扫低密度病灶，增强后更清晰（不能单做平扫）。 “快进快出”。由肝癌血供和正常肝脏血供区别决定。前者90为动脉血供，而后者动脉供血30。肝癌的CT表现6MRI：与CT是手术前重要的辅助检查，用以明确肿瘤与大血管的关系。7DSA（数字减影血管造影）：敏感性最高的检查方法8放射性核素：诊断阳性率80%-90%，9肝穿刺活体组织检查：阳性率不高。六、鉴别诊断1慢性肝炎、肝硬化 2甲胎蛋白阳性的生殖腺胚胎肿瘤3继发性肝癌4肝脏良性肿瘤5肝脓肿6毗邻脏器肿瘤与病变Summarywe have discussed primary liver cancer(PLC), which is one of the most common cancer in China and in the world.Liver is full of blood vessels, including portal vein, hepatic vein,etc. ,which makes it easy for tumor to invade into the veins. Dissemination in liver itself is the predominant type of metastases. Lung, bone and brain are all targets of metastases.PLC develops quickly and prognoses of end stag patients are very poor. So, we should remember that early diagnosis is key point of management of PLC.However, the clinical manifestation of PLC is not typical in the early stage. Presented with hepatomegaly, jaundice and ascites, most patients have lost the opportunity to get operation.Then, how can we get an early diagnosis? The best way by far is establishing surveillance programme. Patients at high risk of developing PLC, defined as man with hepatitis B or C or cirrhosis, in his middle age, should be entered into the surveillance programme. B-type ultrasonograph is of choice which is cheap and non-invasive. AFP plays a key role in diagnosis. It can also be used in follow-up, judging the outcome of the therapy and indicating the recurrence of the tumor. CT and MRI are also valuable in diagnosis and may give us details about the relationship between the tumor and the important structures such as the porta hepatis. Thanks to the hard work of predecessors, we have known more about PLC. Although we all know that there is a long way to go. LET US GO FOR IT!划线部分为板书内容2min幻灯（1-2） 1min幻灯（3-4）本课标题介绍本课的授课内容和重点。3 min幻灯（5-8）指出肝癌总体死亡率几十年来没有改善，主要原因在于早期诊断率低。7 min幻灯（9-12） 讲完病因后和同学互动完成肝癌高危人群的定义。5min幻灯