医学课件：肝细胞癌(英文版)

HepatocellularcarcinomaHepatocellularcarcinomaEpidemiologyHCCistheseventhmostcommoncancerworldwide,andthethirdleadingcauseofcancer-relateddeaths.Morethan600,000newcasesworldwideannually(50%inChina)Over80%ofHCCsoccurindevelopingcountriessub-SaharanAfrica,southeastAsia,andeastAsiaIncidencedecreasedindevelopingcountriesandincreasedindevelopedcountriesYangJD,etal.NatureRev2010EpidemiologyHCCistheseventGlobalvariationinincidenceofHCCYangJD,etal.NatureRev2010GlobalvariationinincidenceEtiologyHepatitisB:50%HCCattributedtoHBVworldwideAround100timeshigherforincidenceofHCCincarriersthannoncarriersHepatitisC:leadingcauseofHCCinWesterncountriesandJapanAflatoxinB:synergisticfactorwithHBVinChinaandsub-SaharanAfricaAlcoholicliverdisease:secondmostcommonriskfactorforHCCafterHCVinUSANonalcoholicsteatohepatitis(NASH):anemergingriskfactorindevelopedcountriesEtiologyHepatitisB:50%HCCPreventionVaccinationofHBVReducedHCCincidenceafteruniversalvaccinationofnewbornbabiesLamivudinetreatmentreducedincidenceofHCCinhepatitisBorresultantcirrhosisPreventionofHCVtransmissionNovaccinationforHCVInfectioncontrolmeasuresinhighriskpractices(screeningblooddonors,useofdisposableneedles,thoroughsterilizationofsurgicalinstruments)InterferonandribavirinforhepatitisCPreventionVaccinationofHBVPathologyofHCCDifferentiationEdmondsongrade:I,II,III,IVPortalveininvasionMicrovessel,macrovessel(portalvein,hepaticvein,Inferiorvenacava)MetastasisDistantmetastasis:lung,lymphnodule,bone,adrenalgland,brain)PathologyofHCCDifferentiatioTumormarkersAlpha-fetoprotein(AFP)HCC:60%70%withelevatedAFPOthers:ActiveHepatitis,livercirrhosisLivermetastasis:Gastriccancer,pancreaticcancer,kidneycancer,embryonictumorsdes--carboxyprothrombin(DCP)TumormarkersAlpha-fetoproteinImaginesUltrasonographyDynamiccomputedtomography(CT)Magneticresonanceimagine(MRI)AngiographyImaginesUltrasonographySurveillanceofHCCIndividualshighriskforHCCHepatitismenover40years,womenover50yearsPatientswithpersistentlyorintermittentlyelevatedalaninetransaminase(ALT)levelsLivercirrhosisHepatitisBorCrelatedAlcoholicliverdiseaseHemochromatosisPrimarybiliarycirrhosisHowtocarryoutthescreeningUltrasonographyincombinationwithserumHCCmarker,alpha-fetoprotein(AFP),every6monthsSurveillanceofHCCIndividualsDiagnosisAmericanAssociationforthestudyofliverDiseases(AASLD)Lesion1.0cm,withHCCfeatures(enhancementinarteryphaseandwashoutinvenousphase)ononeofDynamicimagines(CTorMRI)BiopsyDiagnosisAmericanAssociationDiagnosisofHCCBruixJandShermanM,Hepatology2011DiagnosisofHCCLivercirrhosisCT/MRIOrbiopsyDiagnosisofHCCBruixJandShStagingsystemsBarcelonaClinicliverCancer(BCLC)CanceroftheliverItalianProgram(CLIP)TNM(tumor,nodeandmetastasis)OkudaJapaneseIntegratedstagingscore(JIS)systemsStagingsystemsBarcelonaCliniBCLCstageBruixJandLlovetJM,Lancet2009BCLCstageBruixJandLlovetJDifferentialdiagnosisLivermetastasisColorectal,pancreatic,breast,lung;IntrahepaticcholangiocarcinomaAngiomaLivercystsLiverAbscessDifferentialdiagnosisLivermeTreatmentSurgicaltreatmentSurgicalresectionlivertransplantationTransarterialchemoembolizaionLocalablationPercutaneousethanolinjection(PEI)Radiofrequencyablation(RFA)RadiationSyctemictherapyChemotherapy,immunotherapy,moleculartargettherapyTreatmentSurgicaltreatmentSorafenibSorafenibSorafenibinadvancedHCCMediansur6.5mvs4.2mP=0.014Mediantimetoprogress2.8mvs1.4mP=0.0005ChengALetal.LancetOncol2009SorafenibinadvancedHCCMediaPrognosisTumorstageSize,nodules,portalveininvolvement,metastasisBiomarkersLiverfunctionChild-PughECOGperformancePrognosisTumorstageThanksThanksUltrasonographyUltrasonographyMRIT1WT2WArteryphaseVenousphaseMRIT1WT2WArteryphaseVenousphCTNonenhancement,EnhancementinarteryphasewashoutinvenousphaseCTNonenhancement,angiographyangiographyPancreaticcancermetastasistotheliverPancreaticcancermetastasistIntrahepaticcholangiocarcinomaIntrahepaticcholangiocarcinomangiomaangiomaLivercystLivercystSurgicalresectionSurgicalresection

n5-yOStransplantation

46875.7%surgicalresection samlllivercancer

505957.0% largelivercancer

486030.3%Long-termsurvivalofHCCtreatedwithsurgicalresectionandtransplantation(1958-2009)

TransarterialchemoembolizationTransarterialchemoembolizatioPercutaneousethanolinjectionPercutaneousethanolinjectionRadiofrequencyablationRadiofrequencyablationRFAforHCCRFAforHCCSmallHCCtreatedwithradiofrequencyablation（zhongshanhospitaln=864)≤5cm:Medialsurvival42m5-yearsurvavalrate:34.7%≤3cm:Medialsurvival62m5-yearsurvvalrate：50.6%P<0.0001SmallHCCtreatedwithradiofrHepatocellularcarcinomaHepatocellularcarcinomaEpidemiologyHCCistheseventhmostcommoncancerworldwide,andthethirdleadingcauseofcancer-relateddeaths.Morethan600,000newcasesworldwideannually(50%inChina)Over80%ofHCCsoccurindevelopingcountriessub-SaharanAfrica,southeastAsia,andeastAsiaIncidencedecreasedindevelopingcountriesandincreasedindevelopedcountriesYangJD,etal.NatureRev2010EpidemiologyHCCistheseventGlobalvariationinincidenceofHCCYangJD,etal.NatureRev2010GlobalvariationinincidenceEtiologyHepatitisB:50%HCCattributedtoHBVworldwideAround100timeshigherforincidenceofHCCincarriersthannoncarriersHepatitisC:leadingcauseofHCCinWesterncountriesandJapanAflatoxinB:synergisticfactorwithHBVinChinaandsub-SaharanAfricaAlcoholicliverdisease:secondmostcommonriskfactorforHCCafterHCVinUSANonalcoholicsteatohepatitis(NASH):anemergingriskfactorindevelopedcountriesEtiologyHepatitisB:50%HCCPreventionVaccinationofHBVReducedHCCincidenceafteruniversalvaccinationofnewbornbabiesLamivudinetreatmentreducedincidenceofHCCinhepatitisBorresultantcirrhosisPreventionofHCVtransmissionNovaccinationforHCVInfectioncontrolmeasuresinhighriskpractices(screeningblooddonors,useofdisposableneedles,thoroughsterilizationofsurgicalinstruments)InterferonandribavirinforhepatitisCPreventionVaccinationofHBVPathologyofHCCDifferentiationEdmondsongrade:I,II,III,IVPortalveininvasionMicrovessel,macrovessel(portalvein,hepaticvein,Inferiorvenacava)MetastasisDistantmetastasis:lung,lymphnodule,bone,adrenalgland,brain)PathologyofHCCDifferentiatioTumormarkersAlpha-fetoprotein(AFP)HCC:60%70%withelevatedAFPOthers:ActiveHepatitis,livercirrhosisLivermetastasis:Gastriccancer,pancreaticcancer,kidneycancer,embryonictumorsdes--carboxyprothrombin(DCP)TumormarkersAlpha-fetoproteinImaginesUltrasonographyDynamiccomputedtomography(CT)Magneticresonanceimagine(MRI)AngiographyImaginesUltrasonographySurveillanceofHCCIndividualshighriskforHCCHepatitismenover40years,womenover50yearsPatientswithpersistentlyorintermittentlyelevatedalaninetransaminase(ALT)levelsLivercirrhosisHepatitisBorCrelatedAlcoholicliverdiseaseHemochromatosisPrimarybiliarycirrhosisHowtocarryoutthescreeningUltrasonographyincombinationwithserumHCCmarker,alpha-fetoprotein(AFP),every6monthsSurveillanceofHCCIndividualsDiagnosisAmericanAssociationforthestudyofliverDiseases(AASLD)Lesion1.0cm,withHCCfeatures(enhancementinarteryphaseandwashoutinvenousphase)ononeofDynamicimagines(CTorMRI)BiopsyDiagnosisAmericanAssociationDiagnosisofHCCBruixJandShermanM,Hepatology2011DiagnosisofHCCLivercirrhosisCT/MRIOrbiopsyDiagnosisofHCCBruixJandShStagingsystemsBarcelonaClinicliverCancer(BCLC)CanceroftheliverItalianProgram(CLIP)TNM(tumor,nodeandmetastasis)OkudaJapaneseIntegratedstagingscore(JIS)systemsStagingsystemsBarcelonaCliniBCLCstageBruixJandLlovetJM,Lancet2009BCLCstageBruixJandLlovetJDifferentialdiagnosisLivermetastasisColorectal,pancreatic,breast,lung;IntrahepaticcholangiocarcinomaAngiomaLivercystsLiverAbscessDifferentialdiagnosisLivermeTreatmentSurgicaltreatmentSurgicalresectionlivertransplantationTransarterialchemoembolizaionLocalablationPercutaneousethanolinjection(PEI)Radiofrequencyablation(RFA)RadiationSyctemictherapyChemotherapy,immunotherapy,moleculartargettherapyTreatmentSurgicaltreatmentSorafenibSorafenibSorafenibinadvancedHCCMediansur6.5mvs4.2mP=0.014Mediantimetoprogress2.8mvs1.4mP=0.0005ChengALetal.LancetOncol2009SorafenibinadvancedHCCMediaPrognosisTumorstageSize,nodules,portalveininvolvement,metastasisBiomarkersLiverfunctionChild-PughECOGperformancePrognosisTumorstageThanksThanksUltrasonographyUltrasonographyMRIT1WT2WArteryphaseVenousphaseMRIT1WT2WArteryphaseVenousphCTNonenhancement,Enhancementinarteryphasewashoutinvenousphase