内科学教学课件：10 hepatocellular carcinoma

HepatocellularcarcinomaEpidemiologyHCCistheseventhmostcommoncancerworldwide,andthethirdleadingcauseofcancer-relateddeaths.Morethan600,000newcasesworldwideannually(50%inChina)Over80%ofHCCsoccurindevelopingcountriessub-SaharanAfrica,southeastAsia,andeastAsiaIncidencedecreasedindevelopingcountriesandincreasedindevelopedcountriesYangJD,etal.NatureRev2010GlobalvariationinincidenceofHCCYangJD,etal.NatureRev2010EtiologyHepatitisB:50%HCCattributedtoHBVworldwideAround100timeshigherforincidenceofHCCincarriersthannoncarriersHepatitisC:leadingcauseofHCCinWesterncountriesandJapanAflatoxinB:synergisticfactorwithHBVinChinaandsub-SaharanAfricaAlcoholicliverdisease:secondmostcommonriskfactorforHCCafterHCVinUSANonalcoholicsteatohepatitis(NASH):anemergingriskfactorindevelopedcountriesPreventionVaccinationofHBVReducedHCCincidenceafteruniversalvaccinationofnewbornbabiesLamivudinetreatmentreducedincidenceofHCCinhepatitisBorresultantcirrhosisPreventionofHCVtransmissionNovaccinationforHCVInfectioncontrolmeasuresinhighriskpractices(screeningblooddonors,useofdisposableneedles,thoroughsterilizationofsurgicalinstruments)InterferonandribavirinforhepatitisCTumormarkersAlpha-fetoprotein(AFP)HCC:60%70%withelevatedAFPOthers:ActiveHepatitis,livercirrhosisLivermetastasis:Gastriccancer,pancreaticcancer,kidneycancer,embryonictumorsdes-

-carboxyprothrombin(DCP)ImaginesUltrasonographyDynamiccomputedtomography(CT)Magneticresonanceimagine(MRI)AngiographySurveillanceofHCCIndividualshighriskforHCCHepatitismenover40years,womenover50yearsPatientswithpersistentlyorintermittentlyelevatedalaninetransaminase(ALT)levelsLivercirrhosisHepatitisBorCrelatedAlcoholicliverdiseaseHemochromatosisPrimarybiliarycirrhosisHowtocarryoutthescreeningUltrasonographyincombinationwithserumHCCmarker,alpha-fetoprotein(AFP),every6monthsDiagnosisAmericanAssociationforthestudyofliverDiseases(AASLD)Inthebackgroundoflivercirrhosis,liverLesion1.0cm,withHCCfeatures(enhancementinarteryphaseandwashoutinvenousphase)ononeofDynamicimagines(CTorMRI)BiopsyDiagnosisofHCCBruixJandShermanM,Hepatology2011StagingBarcelonaClinicliverCancer(BCLC)CanceroftheliverItalianProgram(CLIP)TNM(tumor,nodeandmetastasis)OkudaJapaneseIntegratedstagingscore(JIS)systemsBCLCstageBruixJandLlovetJM,Lancet2009TreatmentSurgicaltreatmentSurgicalresectionlivertransplantationTransarterialchemoembolizaionLocalablationPercutaneousethanolinjection(PEI)Radiofrequencyablation(RFA)RadiationChemotherapyMoleculartargettherapy:sorafenibPrognosisTumorstageSize,nodules,portalveininvolvement,metastasisBiomarkersLiverfunctionChild-PughECOGperformanceThanksUltrasonographyMRIT1WT2WArteryphaseVenousphaseCTNonenhancement,EnhancementinarteryphasewashoutinvenousphaseangiographySurgicalresection

n5-yOStransplantation

46875.7%surgicalresection samlllivercancer

505957.0% largelivercancer

486030.3%Long-termsurvivalofHCCtreatedwithsurgicalresectionandtransplantation(1958-2009)TransarterialchemoembolizationThemediansurvival:BCLCA:47.0monBCLCB:20.5monBCLCC:8.0monTACEforunresectableHCC(n=1816)PercutaneousethanolinjectionRFAforHCCLong-termsurvivalofsmalllivercancertreatedwithRFATheestimated1-,3-,5-,and10-yearsurvivalrateswere91.4,71.3,54.6,and33.2%,respectivelyThe1-,3-,5-,and10-yearrecurrence-freesurvivalrateswere74.4,43.8,30.1,and15.2%,respectivelyN=837(1020nodules)Inclusion:tumordiameterB3cmandnomorethanthreenodules)ZhangL,MedOncol(2015)SBTRachievedasimilarefficiencywithRFAFOLFOX4vs

DoxorubicininadvancedstageHCCOverallsurivalmedianOS=6.40mvs4.97m(P=.07;