外科学 肝脏疾病(英文)

LiverDiseases

肝脏疾病1Thistalkwasbasedonbutnotlimitedto:郑树森陈孝平吴在德DavidC.SabistonLawrenceW.Way2肝脏的传说普罗米修斯的传说肝脏不可或缺：动物摘除肝脏，只能存活50小时肝脏的功能：化工厂代谢（糖、蛋白、脂肪、维生素、激素）、胆汁、解毒、免疫、凝血、再生损害肝脏的原因：病毒、药物、酒精、食物污染、肥胖、不良习惯、情绪3Catalogue

Anatomy&PhysiologyNeoplasmsofliverPrimarylivercancer☆☆☆☆☆MetastasisneoplasmsBenignlesionsLiverabscess4EssentialsofAnatomy-1Theliverliesintherightupperquadrantoftheabdomen,undertheprotectiveribcage,beneaththediaphragmandconnectedtothedigestivetractbymeansofportalveinandbiliarydrainagesystem.Gilsson’scapsule,barearea,falciformlig.,coronarylig.,gastrohepaticlig.,hepatoduodenallig.Winslow’sforamen

1:liver;2:ribcage;3:spine;4:pelvis

5History

--Childhoodoflivercancersurgery1888年，Langenbuch,1sthepatectomy(mass)1891年，Lucke,lefthepatectomy(livertumor)1899年，William,3casessuccessfulhepatectomy1911年，Wendel,firstrighthepatectomy(livertumor)CarlLangenbuch(1846-1901)2.HuangZQ.DigestiveSurgery,2002,1(1):1-6.3.YMJiang.JShandongMedUniv2000;3:20-3.Difficulty:complexanatomy,bleedingcontrol6History

--AnatomyboostliversurgeryCouinaudsegmentalsystemSincemid-20thcentury,liveranatomydevelopmentensuredominantroleofsurgeryinlivercancertherapy1951，Hjortsjo(Switzerland)-segmentaldistributionofhepaticartery&biliarytracts1954，Couinaudsegmentalsystem2.HuangZQ.DigestiveSurgery,2002,1(1):1-6.3.YMJiang.JShandongMedUniv2000;3:20-3.7Essentialsofanatomy-2American(lobar)systemFrench(Couinaudsegmental)system.ClaudeCouinaud(16February1922,-4May2008)8ClaudeCouinaud

(16Feb1922,-May2008)Epitaph:abelatedadvertisementforalineofgoodsthathaspermanentlydiscontinued.(墓志铭:是一则已经永久断市的货物的过时广告)9ClaudeCouinaud

(16Feb1922,-May2008)CLAUDECOUINAUDisaFrenchsurgeonandanatomistwhomadesignificantcontributionsinthefieldofhepatobiliarysurgery.Heperformeddetailedanatomicstudiesoftheliverandwasthefirsttodescribeitssegmentalanatomy.Hedevelopedtheconceptofplatesandvasculobiliarysheathsoftheliver,andperformedthefirst"controlled"hepatectomybyisolatinganddividingtheGlissoniansheathsgoingintotheliver,priortoparenchymaldissection.Healsoperformedthefirstbiliarybypasstothelefthepaticductandthefirst"segmentIIIbypass."HisbookLeFoie:EtudesAnatomiqueetChirurgicalesstandsastheseminalworkonhepatobiliarysurgeryandanatomyofthe20thcentury.ArchSurg.2002;137(11):1305-1310.doi:10.1001/archsurg.137.11.1305.10EssentialsofAnatomy-311EssentialsofAnatomy–4-CauinaudSegmentation12EssentialsofAnatomy–5----lefthepaticvein13Essentialsofanatomy–6----middlehepaticvein14Essentialsofanatomy–7-portalveinplane15aweb-basedinteractive3Dteachingmodelof

surgicalliveranatomy:http://pie.med.utoronto.ca/VLiver/16Essentialsofanatomy–8

----Howgoodwecoulddo?17“EraofPrecisionLiverSurgery”

--accurateimaging,advancedtools,meticulousskills18南方医科大学珠江医院：数字影像技术应用于肝胆胰外科（三维可视+虚拟手术）BaseofPrecisionLiverSurgery

--Accurateimagingtechnology19ItalianNationalTumorInstitute（INT）

----Imaging：CT3-DreconstructionPre-operationevaluation-120ItalianNationalTumorInstitute（INT）

----Imaging：livervolumeestimationPre-operationevaluation-221GMU–1stAffiliatedHospital

----EDDAImaging：CT3-DreconstructionPre-operationevaluation-222Pre-operationevaluation-3ItalianNationalTumorInstitute（INT）---liverfibrosisevaluation：fibroscan23“EraofPrecisionLiverSurgery”

—Leftloberesection(preservingMHV)24“EraofPrecisionLiverSurgery”

—Seg.6,7resection(preservingRHV)25“EraofPrecisionLiverSurgery”

—Seg5,6accurateallocation26“EraofPrecisionLiverSurgery”

—blockSeg-5Glissonsheath27“EraofPrecisionLiverSurgery”

--BlockSeg-5，8Glissonsheath28“EraofPrecisionLiverSurgery”

--BlockSeg-6Glissonsheath29“EraofPrecisionLiverSurgery”

--grossinspectionpathology30“EraofPrecisionLiverSurgery”

--removalofSeg.5&631

Theliverreceivesdualbloodsupply(75%

viaportalvein&25%

viahepaticartery).50%oxygensupplyviaportalvein&50%

viahepaticartery

Ligationofportalveiniscatastrophic

Pringle’smaneuver:~15-20minEssentialsofanatomy–9-circulation32Metabolism:bilirubin,carbohydrate,lipid,protein,vitamin,drugs&toxins,...CoagulationImmuneregulationRegenerationIndicesofliverfunction:Livertransaminases:aspartatephosphatase(AST),alaninephosphatase(ALT)Alkalinephosphatases(ALP),Gamma-glutamyltranspeptidase(GGT)Albumin,pre-albuminChild-Pughclassification;ICG-15Essentialsofphysiology

---liverfunction

33Child-PughclassificationPughRNH,Murray-LyonIM,DawsonJL,PietroniMCandWilliamsR.

Transectionoftheesophagusforbleedingesophagealvarices.

Brit.J.Surg.60:646-654,1973.

**LuceyMR,BrownKA,EversonGT,FungJJ,GishR,KeeffeEB,etal.

MinimalCriteriaforPlacementofAdultsontheLiverTransplantWaitingList

LiverTransplantationansSurgery,Vol.3,No6(November),1997:pp628-637Pre-operationevaluation-434ItalianNationalTumorInstitute（INT）---liverfunctionevaluation：ICGretentionratePre-operationevaluation-535HepaticTrauma

(skip)

36LiverNeoplasms37Categorization

benign：hemangioma，adenoma

primarylivercancermalignant：

secondary：metastasis38PrimaryLiverCancer

☆☆☆☆☆

39PrimaryLiverCancerHistopathologytypes:肝细胞癌：Hepatocellularcarcinoma(HCC);>90%；胆管细胞癌：Cholangiocellularcarcinoma(cholangiocarcinoma);≦5%混合细胞型肝癌：Mixedform(hepatocholangioma).1%~2%Andmore:---中国《原发性肝癌诊疗规范（2011年版）》40ICC—pathologistcouldmakemistakes!41Background--overview

Hepatocellularcarcinoma(HCC)isarelativelyraremalignancyinthewesternworld,butoneofthemostfrequentfataltumorsinthesub-SaharanAfrican,SoutheastAsia,Japan,thepacificIslands,GreeceandItalywherethemajoritymankindlives.Hadbeenconsideredas“in-curabledisease”.Frequentlydetectedonlywhenpalpablemassordramaticclinicalsymptomsencouragedthroughclinicalinvestigation.DiagnosisandtreatmenthavebeenimprovedalotinthepastdecadesOptimized5-yrssurvivalafterradicalresectionis30~70%.

42Background-etiologyHepatitisvirusinfection(HBV,HCVetal.)Mycotoxins(aflatoxins)Contaminatedwater(pondorditchwater)OthercausesGeneticfactorsAlcoholiccirrhosisAlpha-antitrypsindeficiencyHemochromatosisPlantalkaloidOralcontraceptivesAndrogensVinylchlorideTraceelements(?):Cu,Zn,NiandCoParasites:Clonorchissinensis4344坏死Multiplemechanismsimplicatedinhepatocarcinogenesis--complexityofHCCFaraziPA,DePinhoRA.NatRevCancer.2006;6:674-687.Abnormalliver

nodulesExtensivescarring

(collagen)Hepatocellular

carcinomaDysplastic

noduleHyperplastic

noduleProliferationHBVHCVAlcoholAflatoxinB1InjuryHepatocyte

proliferative

arrest

Stellatecell

activationChronicliverdiseaseLivercirrhosisModerategenomic

instabilityMarkedgenomic

instabilityLossofp53WelldifferentiatedModeratelydifferentiatedPoorlydifferentiatedNecrosis45Epidemiology-WorldwideHCCsareincreasinginfrequencyinmanypartsoftheworld.HCCismorecommonincertainareas.IncidenceinAfrica:164.6/100000(Mozambique)Standardizedincidencerates1--7/100000/year(USA)4—9timesmorefrequentlyinmenthaninwomen;1:1ingroupwithoutpreexistentliverdisease.6timeshigherforOrientalsinUSAthanwhitepopulation.

46Epidemiology-China1995nationwidesurveyofcancermortalitymortality20.40/100,00029.07/100000(men)11.23/100,000(women)Since1990s,NO2.tumorkiller(followinglungcancerinurbanareasand,gastriccancerincountryside)andtheleadingcauseofcancerdeathamongChineseaged15~34.ThemainendemicareasarealongthesoutheastseacoastofChina,wheretheclimateiswarmandhumid.Thecountieswiththehighestmortality(≥30/100000)are:Fusui(GuangxiZhuangAutonomousRegion),Qidong(Jiangsu),Zhoushan(Zhejiang)andTungan(Fujian).47China—HCCpandemicareaGLOBOCAN2008(IARC),SectionofCancerInformation(19/10/2010)http://globocan.iarc.fr/factsheets/cancers/liver.asp03.05.38.317.6117

Age-standardisedincidenceratesper100,000Malemorbidity:34.7/100,000（292,966例）Femalemorbidity:13.7/100,000（109,242例）Malemortality:34.1/100,000（226,830例）Femalemortality:13.1/100,000（105,249例）Over55%ofGlobalHCCMales:females(2.67:1)

Epidemiology-148

Epidemiology-2HCCmortalitydistribution(China)49Guangxiishigh-riskareaforHCCPopulation:45million(~40%areZhuangminorities)Climate:generallyhotandhumid.TheTropicofCanceracrossthemiddleofGuangxi,separatesthenorthern&southernpart.GuangxihasthehighestcrudemortalityrateofHCCHCCaccountsfor1/3ofallcancerdeaths(50%inmalesand25%infemales).MostHCCpatientsarefarmers.Hepatitisvirus,aflatoxinandcontaminatedwaterarerecognizedriskfactors.

Epidemiology-350HCCmortalitydistribution(Guangxi)

Epidemiology-451PathologyGrossclassification:Massiveform:singlepredominantmassNodularform:multiplenodulesDiffuseform:infiltrativetumorsthroughouttheparenchyma.Differentiation:Ⅰ~ⅣEncapsulatedtumorshavearelativelyfavorableprognosis.(Fibrolamellarhepatoma)Metastasis:Lymphnodes(hilar,celiac)LungPeritonealcavityPortalorhepaticveins

52“Early-stageHCC”&“Small-HCC”Early-stageHCC(sub-clinicalHCC):nosymptoms&signs

“Micro-HCC”微小肝癌：Ф≤2.0cm“SmallHCC”小肝癌：2.0cm<Ф≤5.0cm“LargeHCC”大肝癌：5.0cm<Ф10.0cm“Extra-largeHCC”巨大肝癌：Ф>10.0cm53Hepatocellularcarcinoma,liver,grossA2.0cmHCCarisinginachronicviralhepatitis;thetumor,whichhadapredominantacinararchitecture,producedabundantbile.54Hepatocellularcarcinoma,liver,grossNoduleofhepatocellularcarcinomainchronichepatitisC;thepalegoldenyellowcoloriscommon.55Hepatocellularcarcinoma,liver,grossTheneoplasmislargeandbulkyandhasagreenishcastbecauseitcontainsbile.Totherightofthemainmassaresmallersatellitenodules.The

satellitenodules

ofthishepatocellularcarcinomarepresenteitherintrahepaticspreadofthetumorormulticentricoriginofthetumor.56Satellitenodules&

Tumorembolus57Hepatocellularcarcinoma,liver,grossAnotherhepatocellularcarcinomawithagreenishyellowhue.Suchmassesmayalsofocallyobstructthebiliarytractandleadtoanelevatedalkalinephosphatase58HCC(fibrolamellarcarcinoma),grossWelldemarcatedfibrolamellarcarcinomawithcentralscar;thesurroundingliverisnormal.Coarselamellarfibrosisischaracteristichistologically;notethepalebodyinthelargeeosinophilicmalignanthepatocyte(X40).59Hepatocellularcarcinoma,liver,microscopicThemalignantcellsofthisHCC(seenmostlyontheright)arewelldifferentiatedandinterdigitatewithnormal,largerhepatocytes(seenmostlyattheleft)ThisHCCiscomposedoflivercordsthataremuchwiderthanthenormalliverplatethatistwocellsthick.Thereisnodiscernablenormallobulararchitecture,thoughvascularstructuresarepresent.60Clinicalfindings-1Symptomsandsigns:

Rightupperquadrantpainordiscomfortwithorwithoutreferredpainintherightshoulder.WithorwithouthepatomegalySuddendeteriorationinacirrhoticpatient:weightloss,weakness,intermittentfever,jaundice,varicealbleeding,asciteswithorwithoutblood.Rarecasesmaymanifestmetabolicorendocrineabnormalities:erythrocytosis,hypercalcemia,hypoglycemicattacks,Cushing’ssyndrome,orvirilization.61Clinicalfindings-2Laboratoryfindings:

Serumbilirubin:nonspecificAlkalinephosphatase:nonspecificHBsAg,HCV-Ab:nonspecificAFP

(alpha-fetoprotein):elevateinabout70~80%HCCs;Maybefalsepositiveamongchronicactivehepatitis,acutehepatitis,testiculartumorsandpregnantwomen.Markerforpostoperativefollow-up(HL6~7d).Upperlimitinserumis20ng/ml;>200ng/mlissuggestiveofHCC.62Clinicalfindings-3

Imagingfindings:

(number,location,size,neighboring,PVTT,cirrhosis,HPV)Ultrasoundscan(screening):resolution~2cmCTscan(portographyorCE):resolution1~2cmMRIscanissuperiorinshowingthelesionevolvinghepaticveins.resolution1~2cmAngiography:resolution~1cm1)

HCCismorevascularthantheadjacentparenchyma2)

Cholangiocarcinomaislessvascular3)

Hemangiomahaspatchyvascularpooling4)

Venousphaseofasuperiormesentericarterialinjectionmayshowoccupationintheportalvein.5)Angiographywithiodizedoil(Lipiodol)followed2-weekslaterbyCTscancoulddemonstratesmallHCC.

63HCC-Imagingfindings

(DSA)64HCC-ImagingfindingsBeforeinterventiontherapyAfterinterventiontherapy65HCC-ImagingfindingsArterialphasePortalveinphase66Biopsy&screeningLiverbiopsy:percutaneouscorebiopsyoraspirationbiopsy(notsoriskyforbleedingifdoingunderUS-guidance,butseedingoftumorcellsalongpuncturechannelispossible.)Screening:usingUS+AFPforscreeningHCCamonghigh-riskpopulation(chronicliverdiseases),manyearly-stageHCCwerefoundandtreated,resultinginmorefavorableoutcomes.67HCCisamenabletobiopsybypercutaneousneedlebiopsyThearchitecturaldistortionduetocirrhosisisevident;atoneendthetissueappearsquitefragmented(X8).ThepresenceofmacrotrabeculararchitectureinthisfragmentedareaallowedforestablishingthediagnosisofHCC(X40).68EssentialsforDiagnosisHigh-riskpopulation:male,>40yrs,HBV/HCV(+),alcohol,cirrhosis,familyhistorySymptoms&signs:AFP:RI-AFP≥400ng/ml,>4weeks,exclusionofpregnancy,activehepatitis,embryonictumorsImaging:B-US,CT,MRI,DSABiopsy:Diag.Criteriafromdifferentsocietiesarefundamentallyidentical6970原发性肝癌的诊断-pathologycriteria肝脏占位病灶或者肝外转移灶活检或手术切除组织标本，经病理组织学和/或细胞学检查诊断为HCC，此为金标准。---中国《原发性肝癌诊疗规范（2011年版）》71原发性肝癌的诊断-clinicalcriteria在所有的实体瘤中，唯有HCC可采用临床诊断标准，一般认为主要取决于三大因素，即慢性肝病背景，影像学检查结果以及血清AFP水平。---中国《原发性肝癌诊疗规范（2011年版）》72原发性肝癌的诊断-

clinicalcriteria要求在同时满足以下条件中的（1）+（2）a两项或者（1）+（2）b+（3）三项时，可以确立HCC的临床诊断：（1）具有肝硬化以及HBV和/或HCV感染（HBV和/或HCV抗原阳性）的证据；（2）典型的HCC影像学特征:同期多排CT扫描和/或动态对比增强MRI检查显示肝脏占位在动脉期快速不均质血管强化（Arterialhypervascularity），而静脉期或延迟期快速洗脱(Venousordelayedphasewashout)a.如果肝脏占位直径≥2cm，CT和MRI两项影像学检查中有一项显示肝脏占位具有上述肝癌的特征，即可诊断HCC；b.如果肝脏占位直径为1-2cm，则需要CT和MRI两项影像学检查都显示肝脏占位具有上述肝癌的特征，方可诊断HCC，以加强诊断的特异性（3）血清AFP≥400μg/L持续1个月或≥200μg/L持续2个月，并能排除其他原因引起的AFP升高，包括妊娠、生殖系胚胎源性肿瘤、活动性肝病及继发性肝癌等---中国《原发性肝癌诊疗规范（2011年版）》73DifferentialdiagnosisOtherabdominaltumorsMetastatictumorsLiverabscessLivercirrhosis74Early-detectionhard1ProgressionfastNaturalhistory（withouttreatment、literatures）HCC:naturalhistory&prognosis1.BruixJandShermanM,Hepatology2005;42:1208-362.VillaEetal.Hepatology2000;32:2333.LlovetJMandBruixJ.JHepatol2008;48:S20-S374.LlovetJMetal,Lancet2003;362:1907HCCstagingEarly2BCLCAMiddle3BCLCBLate3BCLCCEnd-stage3BCLCDNaturalcourse5yrs--20%*16m6m3-4m*Bestreportsinliteratures75PrinciplesoftreatmentforHCCEarlydetection，earlyinterventionSurgicalresectionofferthebestprognosisforearlyHCCsSystemic&individualizedtherapiesarecrucialforbetterprognosisAggressivetherapyforrecurrentHCCcouldimprovesurvival76EvolutionofHCCtherapy19世纪末1950s1960s肝切除术肝叶切除肝移植1970~80s介入治疗术后辅助化疗2000s分子靶向治疗SHARPOriental1994年首项术后TACERCT发表BrJSurg1995;82:1221990s2001发表首项术后化疗Meta分析Cancer.2001,91(12):2378免疫治疗90年代初兴起IFN等治疗病毒肝炎性HCC1888年，Langenbuch有目的地成功施行了第一例肝切除术1954年，Couinaud提出较为完备的肝脏八段法功能解剖1963年ThomasStarzl等人完成了首例人肝移植放疗1965年，Ingold等首次报道了40例肝癌患者的放疗效果小肝癌切除化疗多项化疗RCT未显示生存获益77Treatment—availableweaponsFactorsinfluencingdecision-makingTumor：size,number,locationLiverbackground：cirrhosis,hepatitis,functionGeneralconditionRadicaltherapyforearlyHCCresectionLivertransplantationRegionalablationSystemictherapyformid/endstageHCCRegionaltherapy：TAE、TAC、TACE、TAREablation(RF、PEI、MCT；radiation；HIFU)Systemictherapy：chemo、immuno、targetedtherapy78AlgorithmofdecisionmakingSlightlydifferenceamongdifferentguidelines(societies)79极早期(0)PS0,CPA早期(A)PS0,CPA-B中期(B)PS0,CPA-B晚期(C)PS1-2,CPA-B终末期(D)PS>2,CPCHCC随机对照试验（50%）中位生存时间11-20月

对症(20%)生存期<3月HCC

BCLCstagingandtreatmentSemLivDis1999toJHepatol2008;48:S20-S37治愈性治疗（30％）5年生存率40%-70%LTRF/PEIresection伴随疾病有无≤3个结节,≤3cm上升正常单发结节,<2cm门脉压力/胆红素单发结节多结节,≤3cmTACE多个肿瘤门脉转移,N1,M1PS:performancestatus，ECOG体能状态评分CP:Child-Pugh评级新药治疗Sorafenib80Japanesealgorithm81HongKongalgorithm82Italianalgorithm83中国决策树-卫生部肝细胞癌诊疗规范（2011版）根治手术姑息手术

无法手术中国肝癌诊疗HCCPS0~2PS3~4血管侵犯Child-PughC无有全身状况肝功能肝外转移Child-PughA/B无有肿瘤数目·TACE·手术切除·放疗·分子靶向治疗·系统化疗1个2~3个≥4个肿瘤大小≤3cm＞3cm治疗选择·TACE·手术切除·+局部消融肝移植·手术切除·局部消融≤3cm·肝移植·手术切除·TACE+消融·肝移植<5cm≥5m·支持治疗·肝移植

支持治疗TACE放疗分子靶向治疗系统化疗等84Treatment-Partialhepatectomy

Radicalresectionoffersalmosttheonlypossibilityofcure.

Criteriaoftheradicalresection:absenceofdistantmetastasisorinvasionofhepaticorportalveins;tumor(s)entirelyencompassedbyexcisionofsegment(s)orlobe(s).85Treatment-PartialhepatectomyIndicatorsforapoorprognosisafterresection:>50yrsCoexistenceofliverdiseases(cirrhosis)VascularinvasionPortalveinthrombosisLocateddeepinsideliverintracapsularinfiltrationoftumorcellsbilobarinvolvementMorethanonedepositoftumor86Treatment-Partialhepatectomy

Prognosis:

>70%recurrencein5yrs,couldbemono-centerormulti-centerinorigin.Follow-upusingUS+AFPcoulddetectrelapsedtumoratearlystage,andrepeatresectionsprovidefavorableoutcomestosomecases.InChina,~30%5-yearsurvival(overall);~60%5-yearsurvival(earlystageHCC)*Manypatientsdieofcirrhosis(varicealbleeding,liverfailure)ratherthanrecurrence.*中华医学杂志,2003,83(12):1053-7.87Reality---concominantchronicliverdiseases肝癌肝炎肝硬化MedClinNAm89(2005)371–389NEnglJMed.1997Dec11;337(24):1733-45HCCHepatitisCirrhosis15~20%

在5年内发展至肝硬化肝硬化患者的HCC年发病率约为3-6%90%的肝癌患者伴发肝炎、肝硬化预后这意味着随访100例肝硬化患者5年，有可能发现15例肝癌881Survivalover14yrsSurvivalover25yrsLong-timeSurvivors’gatheringHepatobiliarySurgeryDepartmentOfThe1stAffiliatedHospitalofGMUGuangxiisanepidemicareaforHapetocellularcarcinoma(HCC).Overall5-yrs-survivalpost-resectionisabout30%.89Future：robotichepatectomy

（imageguidedsurgery）港东医院(PYNEH)90Treatment-Livertransplantation

Oftheoreticadvantagebecause:Applicablefortumorstoolargeormultifocaldistribution.Applicableforcirrhoticpatients.ApplicableforhepatitispatientsbecauseeffectiveantiviraltherapyisnowavailableEnsuingbetterqualityoflifeforcirrhoticpatients.ItisofevidentnowthatLTprovidesequivalentsurvivaltoearlystageHCCs,incontrasttohepatectomy.911Post-transplantation92Child-born10yrsafterlivertransplantationforHCC93Treatment-Palliativetherapy

Percutaneousethanolinjection(PEI)orradiofrequencyablation(RF):producenecrosisofsmallHCC.Itisbestsuitedtoperipherallesions,lessthan3cmindiameter.

Arterialchemoembolization:Theoreticbasis:HCCobtainsbloodsupplymainlyfromhepaticartery;embolizationproducesischemaandslowsthewashoutofthedrugs.Theoreticflaw:tumorcellsintheperipheralpartreceivebloodsupplyfromportalveinandhepaticartery(dual-blood-supply).Chemoembolisationcanproducetumornecrosisandhasbeenshowntoaffectsurvivalinhighlyselectedpatientswithgoodliverreserve.

94Treatment-Palliativetherapy

2.YMJiang.JShandongMedUniv2000;3:20-3.95Targetedtherapy:SorafenibSHARP研究－－NewEnglandJournalMedicineLlovetJMetal，2008;359:378-90.Oriental研究－－LancetOncologyChengALetal，2008年12月在线发表LlovetJMetal.NEnglJMed2008;359:378-90.ChengALetal.LacnetOncoligy2008Dec17onlinepublish.96Reference：卫生部《原发性肝癌诊疗规范2011年版》97Metastaticneoplasms

oftheliver

98Metastaticneoplasmsoftheliver

-Background

20-timesmorefrequentthanprimarytumorsinliver

Timing：synchronistic，asynchronisticOriginalsites:breast,lung,pancreas,stomach,largeintestine,kidney,ovary,uterus…

Pathway:systemiccirculationportalveinlymphatic

99MetastaticneoplasmsoftheliverThenumerousmasslesionsthatareofvariablesize.Someofthelargeronesdemonstratecentralnecrosis.Themassesaremetastasestotheliver.Thislargesolitarymetastaticnodulewasfromacolonprimary;theglairycutsurfacerepresentsahighmucincontent.100MetastaticneoplasmsoftheliverHerearelivermetastasesfromanadenocarcinomaprimaryinthecolon,oneofthemostcommonprimarysitesformetastaticadenocarcinomatotheliverMultipleconfluentnoduleswithcentralumbilicationandperipheralhyperemiaareclassicformetastasistoliver;theprimaryherewasabreast

carcinoma.101Metastaticneoplasmsoftheliver

-ClinicalfindingsSymptomsandsigns:

Generalcomplaints:weightloss,fatigue,anorexiaRightupperabdominalpain,ascites,jaundice,fever,leukocytosis…

PE:hepatomegaly,palpablemass,tenderness,splenomagely,abdominalvenouscollateral,frictionrub.102Metastaticneoplasmsoftheliver

-ClinicalfindingsLaboratoryfindings

Hematocrit30~36%Elevatedbilirubin,AlkalinephosphataseScan-directedpercutaneousbiopsy103Metastaticneoplasmsoftheliver

-ClinicalfindingsImagingfindings

Sonography:initialscreeningContrast-enhancedCT:mostoftenusedMRI,CTportograpgy104Thiscomputedtomographic(CT)scanwithoutcontrastoftheabdomenintransverseviewdemonstratesmultiplemasslesionsresultinginamarkedlyenlargedliverextendingfromrighttonearlytheleftsideoftheupperabdomen.Thesearemetastasesfromacolonicadenocarcinoma.Anormalsizedspleenisseenatthelowerleft105Thiscomputedtomographic(CT)scanwithcontrastoftheabdomenintransverseviewdemonstratesmultiplemasslesionsrepresentingmetastasesfromacolonicadenocarcinoma.Anormalspleenappearsatthelowerrightintheimage(onthepatient'sleft).106Treatment-HepaticresectionIndicationsforaresectionNoextrahepaticdiseasesTechnicallyfeasibleHepaticresectionmaybecurativeformetastasisfrom:colon,pancreaticisletcellcarcinomas,renalcellcarcinomas,carcinoids,anddirectinvasionfromcontiguousorgans.Hepaticresectionmaybefruitlessformetastasisfrom:breast,pancreas,stomach,femalepelvicorgansandlung.107PancreaticoduodenectomyCase:Jobs108109Treatment-ChemotherapyTrans-hepatic-arterycatheterizationforlocalchemotherapyissuperiortosystemicadministration.Hepaticarteryligationandangiographicembolizationisofbenefitinafewpatients.110Reference：2010年

《结直肠癌肝转移诊断和综合治疗指南》--中华胃肠外科杂志2010，Vol13(6):457Nevergiveup！111Hemangiomas

112HemangiomasThemostcommonbenignhepatictumor.Morecommoninfemalesthaninmales(6:1).Andexogenousestrogenissuspectedriskfactor.Mostareasymptomaticandfoundincidentally.Abdominalpainorapalpablemassmaypresentinlarge(>4cm)hemangioma,butspontaneoushemorrhagerarelyhappens.Scintigraphy,CE-CT,MRI,angiographyshowtypicalimageofhemangioma,namely“earlyappearance,delayedclearance”,i.e.,avascularlesionwithdelayedclearingofthecontrastmedium.Avoidbiopsyforsuspectedhemangiomas.Forsymptomaticpatients,>8cmandinfantcases,enucleation,lobectomy,radiotherapy,embolizationarecandidateapproachesonacase-to-casebasis.Oralcontraceptivesshouldbeproscribed.113HemangiomasSequentialchangesduringangiograpgy:

avascularlesionwithdelayedclearingofthecontrastmedium.114HemangiomasMultiplecavernoushemangiomasinayoungwomanwithepisodicabdominalpain;whitetissueinthelargestlesionrepresentsfibrosisindicatingsomedegreeofinvolution.Thehoneycombappearanceandvascularnatureofthisgiantcavernoushemangiomaarereadilyapparentfromthecapsularsurface.115HemangiomasHemangiomashowingcharacteristicsharpdemarcationfromthesurroundingliverand"spongy"texture.Thecutsurfaceofthishemangiomavariesfromhoneycombtospongytofibrotic(photographcourtesyofS.Goetz,M.D.).116HepaticcystsNon-parasitic:congenital,trauma,inflammation,neoplasmparasitic:echinococcosis(cysticvs.alveolar)117HepaticcystsNon-parasiticCongenitalTraumaInflammationNeoplasmparasitic:echinococcosisHepaticcysticechinococcosisHepaticalveolarechinococcosis118HepaticcystsUsuallysolitary,unilocular,andasymptomaticleision.Echinococosisshouldbedifferentiatedinpatientswithoneortwocystsandhistoryofresidencyinlivestockfarms.Polycysticliverdiseasemaybeconcomitantwithpolycysticrenaldiseases(congenitalpolycysticdisease).Clinicalmanifestation:upperabdominaldiscomfort,mass,obstructivejaundice.Managementforthesymptomaticcases:excisionofcystwall(openedorlaparoscopic)locatedinsuperficialportion,unroofinganddepressionofthelargeordeepcysts.119HepaticcystsMultiplecystsarevisibleoncutsurfaceofliver;thecystwallsarethin,translucent,andgrey.Thisisfromacasewithpolycysticdisease;notethesmallgreenbileducthamartomasinthesurroundingliver.Polycysticliverandkidneydisea