肝癌综合治疗PPT课件

Single
3 nodules ≤ 3 cm
Portal pressure/bilirubin Increased
Associated diseases
Normal
No
Yes
Portal invasion, N1, M1
No
Yes
Resection
Liver transplant PEI/RF
Surgical treatments: applicable overall to 30% of HCC at first diagnosis and 2% to 5% of recurrent HCC
TACE
Sorafenib
Symptomatic Nonsurgical treatments: applicable (unless LT)20%
overall to 50% of HCC at first diagnosis and 50% to 70% of
recurrent HCC
治疗的目的
Intermediate stage Multinodular, PST 0
Advanced stage Portal invasion, N1, M1, PST 1-2
Terminal stage
Single
3 nodules ≤ 3 cm
Portal pressure/bilirubin Increased
Associated diseases
Normal
No
Yes
Resection
Liver transplant PEI/RF
TACE
Curative treatments
Llovet JM, et al. J Natl Cancer Inst. 2008;100:698-711. Bruix J, et al. Hepatology. 2005;42:1208-1236.
▪ 肿瘤缩小 ▪ 改善生命质量 ▪ 延长生存 ▪ QALY
HCC 治疗选择
▪ 早期HCC
– 外科切除（肝部分切除） – 肝移植 – 经皮毁损（PEI，RFA，HIFU，冷冻，微波）
▪ 进展期HCC
– TACE – 系统治疗（化疗） – 新治疗 （分子靶向，放疗…）
早期肝癌
早期HCC的手术切除
▪ 根治？ ▪ 根治术后5年生存率：50-70％ ▪ 术后5年复发率： 60-80％
▪ 问题：如何达到根治？如何降低复发？
Pre-operative TACE + Resection
Downstaging resection：术后5年生存率 ≈小肝癌 肝动脉插管＋结扎/ TACE/ Chemotherapy？
▪ 减小瘤体：手术简单，且控制微小病灶 ▪ 减少血供：手术安全 ▪ 减少术中播散
Zhou 2009 Ann Surg 2009;249: 195–202
Pre-operative TACE
▪ Risk：可切除 －－ 不可切除 ▪ 对肝功能差的病人：进一步损害肝功能 ▪ Japan：RCT 结果类似（Sasaki A. Eur J Surg Oncol.
2006;32:773–9.）
肝癌的综合治疗
Multidisciplinary Strategies to Management of HCC
复旦大学肝癌研究所
背景
▪ 绝大多数（80-90％）的HCC合并肝硬化 ▪ HCC治疗策略应考虑对肿瘤作用，并避免肝功能损害 ▪ HCC的分期系统也应同时考虑肿瘤因素，和肝功能损害的严重性 ▪ 至今尚未有公认的HCC的分期系统 ▪ 肝癌的BCLC分期系统目前在西方国家应用较广，对治疗有指导
TACE: Bridge to OLT
▪ Does not improve long-term survival (grade C). ▪ No convincing evidence that TACE allows to expand the
current selection criteria for OLT, nor that TACE decreases dropout rates on the waiting list (grade C). ▪ TACE does not increase the risk for postoperative complications (grade C). ▪ There is insufficient evidence that TACE offers any benefit when used prior to OLT, neither for early nor for advanced HCC.
意义。
HCC的BCLC分期系统和治疗推荐
HCC
PST 0, Child-Pugh A
PST 0-2, Child-Pugh A-B
PST > 2, Child-Pugh C
Very early stage
Early stage
Single < 2 cm Single or 3 nodules
≤ 3 cm, PST 0
Early stage
Single < 2 cm Single or 3 nodules
≤ 3 cm, PST 0
Intermediate stage Multinodular, PST 0
Advanced stage Portal invasion, N1, M1, PST 1-2
Terminal stage
Portal invasion, N1, M1
No
YesSΒιβλιοθήκη rafenibSymptomatic (unless LT)
HCC的BCLC分期系统和治疗
HCC
PST 0, Child-Pugh A
PST 0-2, Child-Pugh A-B
PST > 2, Child-Pugh C
Very early stage
肝移植
▪ 术后复发 （周俭教授） ▪ 肝源等待：Bridge Treatments of Hepatocellular
Carcinoma in Cirrhotic Patients Submitted to Liver Transplantation. Dig Dis Sci (2008) 53:2830–2831