Primary hepatocellular carcinoma is a highly malignant, infiltrative and metastatic cancer, and surgery is preferred for treatment. However, most patients are already in the middle and advanced stages when they are diagnosed and can only receive non-surgical treatments such as intervention, ablation, radiotherapy and chemotherapy. The emergence of molecular targeted drugs represented by sorafenib has provided new options for such patients. At present, there is still a lack of standardized guidance in the diagnosis and treatment of liver cancer in China, and the Expert Consensus on Standardized Diagnosis and Treatment of Primary Liver Cancer, which was prepared by national multidisciplinary experts, came into being. We will introduce the consensus in parts, and invite some of the authors to interpret it at the same time.
1.Preface
Primary liver cancer (PLC, hereinafter referred to as liver cancer) is one of the most common malignant tumors in clinical practice, and the global incidence rate is increasing year by year and has exceeded 626,000/year, ranking the 5th in malignant tumors; deaths are close to 600,000/year, ranking the 3rd in tumor-related deaths. Liver cancer is highly prevalent in China, and currently, the number of incidence in China accounts for about 55% of the world; it ranks second after lung cancer in tumor-related deaths. Therefore, liver cancer is a serious threat to the health and life of our people.
In order to promote the development of clinical oncology in China, improve the level of multidisciplinary standardized and comprehensive treatment and research of liver cancer, actively study and apply high-level evidence from domestic and foreign countries in line with the principles of evidence-based medicine, and formulate clinical practice guidelines for liver cancer in line with China’s national conditions, the Chinese Anti-Cancer Society Liver Cancer Specialty Committee (CSLC), the Chinese Anti-Cancer Society Clinical Oncology Collaborative Specialty Committee (CSCO) and The Hepatocellular Carcinoma Group of the Chinese Medical Association Hepatology Branch co-sponsored the development of this Expert Consensus on Standardized Diagnosis and Treatment of Primary Liver Cancer with the participation of multidisciplinary experts.
On November 10, 2007, April 5, 2008 and August 30, 2008, three expert consensus seminars were held in Shanghai. The meeting was co-chaired by Prof. Ye Shenglong and Prof. Qin Shukui, with the presence of Academician Wu Mengchao, Academician Tang Zhaoyou, Academician Sun Yan and Prof. Guan Zhongzhen, and more than 60 famous experts in the field of liver cancer diagnosis and treatment in China.
During the meeting, experts systematically reviewed the current international guidelines and consensus on liver cancer and discussed a series of issues on diagnosis, surgical treatment (liver resection and liver transplantation), interventional treatment, local ablative treatment (mainly including radiofrequency ablation, microwave ablation and high-intensity focused ultrasound treatment), radiotherapy, biological treatment, molecular targeted therapy, systemic chemotherapy and Chinese medicine treatment for liver cancer. The experts prepared and actively participated in the meeting, based on the principle of respecting evidence-based medical evidence and aligning with international diagnosis and treatment concepts, especially for the current situation and development of liver cancer diagnosis and treatment in China, they expressed their views and pooled their wisdom, and made many good suggestions.
After the meeting, some experts wrote, widely consulted and repeatedly revised, and finally formed the “Expert Consensus on Standardized Diagnosis and Treatment of Primary Liver Cancer”.
2.Evaluation of international guidelines and consensus on diagnosis and treatment of hepatocellular carcinoma
Since most of the liver cancers are hepatocellular carcinoma (HCC), clinical management involves many disciplines such as medicine, surgery, intervention, radiotherapy, Chinese medicine and medical imaging, etc. Therefore, the standardized diagnosis and treatment of hepatocellular carcinoma needs to be discussed and formulated by multidisciplinary experts in order to select the most suitable preferred treatment and comprehensive treatment measures for patients after diagnosis.
Currently, there are international guidelines for the treatment of liver cancer that can be used as reference, including
① National Comprehensive Cancer Network (NCCN) clinical practice guidelines for hepatocellular carcinoma.
②American Association for the Study of Liver Diseases (AASLD) clinical treatment guidelines for HCC.
③ British Society of Gastroenterology (BSG) treatment guidelines.
④Consensus developed by the American College of Surgeons (ACS).
Staging of hepatocellular carcinoma
For the staging of HCC, the guidelines of AASLD, ACS and NCCN are not uniform and have different emphasis.
The TNM staging approach used by the NCCN is the most standardized internationally, but is less recognized because of.
(i) Vascular invasion, which is critical to the treatment and prognosis of HCC, is difficult to determine accurately prior to treatment (especially prior to surgery).
(ii) Treatment of HCC places great emphasis on liver function compensation, while TNM staging does not indicate the patient’s liver function status.
(iii) The TNM staging of each version is highly variable and difficult to compare and evaluate.
AASLD adopts the Barcelona Clinical Liver Cancer (BCLC) staging and treatment strategy, which is more comprehensive in considering tumor, liver function and systemic conditions, and is supported by high-level evidence of evidence-based medicine, and is now more recognized and widely adopted worldwide.
Surveillance and screening for hepatocellular carcinoma
The four international guidelines mentioned above all place great emphasis on early screening and early surveillance of hepatocellular carcinoma, and all are based on evidence-based medical evidence with a high degree of credibility. The views on screening indicators are relatively consistent and mainly include two items: serum alpha-fetoprotein (AFP) and liver ultrasonography.
For men ≥35 years of age, with hepatitis B virus (HBV) and/or hepatitis C virus (HCV) infection, and at high risk for alcoholism, screening is generally performed at 6-month intervals. For AFP >400 μg/L without liver occupancy on ultrasound, care should be taken to exclude pregnancy, active liver disease, and tumors of embryonic origin in the gonads; if this can be ruled out, tests such as CT and/or magnetic resonance imaging (MRI) should be performed. If AFP appears elevated but does not reach the diagnostic level, in addition to the above-mentioned conditions that may cause an increase in AFP should be ruled out, the dynamic changes in AFP should be followed closely, the interval between ultrasound examinations should be shortened to 1 to 2 months, and CT and/or MRI examinations should be performed when needed. If hepatocellular carcinoma is highly suspected, digital subtraction angiography (DSA) hepatic artery iodine oil angiography is recommended.
Diagnosis of hepatocellular carcinoma
The diagnostic criteria for HCC include pathological and clinical diagnostic criteria. Diagnostic methods include serum tumor marker AFP test, imaging examinations (including ultrasound, CT, MRI and DSA) and pathological histological examinations (mainly liver tissue biopsy).
The BSG guidelines suggest that for patients with cirrhosis, the presence of cirrhosis should be determined first, followed by a 2-cm threshold of occupancy size to start the diagnostic process, while for non-cirrhotic patients, the AFP level is used to guide the diagnostic process.
Internationally, the diagnostic process of AASLD is currently applied more often, differentiating between the mass and the diagnostic process by occupancy <1cm, 1~2cm and >2cm, with emphasis on early diagnosis.
Treatment of hepatocellular carcinoma
The consensus of ACS states that the treatment goals of HCC include: (1) cure, (2) local control of tumor in preparation for transplantation, and (3) local control of tumor and palliative treatment. Improving the quality of life is also one of the important treatment goals. Treatment approaches broadly include surgical (hepatectomy, liver transplantation and palliative care surgery), non-surgical (local therapy, arterial chemoembolization, chemotherapy, radiotherapy, biologic therapy and molecular targeted therapy) and other treatments (including participation in clinical studies).
The NCCN emphasizes the importance of keeping up with the times based on following evidence-based medicine. The 2008 edition of its treatment guidelines has introduced breakthroughs in the field of hepatocellular carcinoma treatment in the past two years, namely, the molecular targeted therapy drug sorafenib is listed as one of the standard treatment options for patients with inoperable and advanced HCC.
3.Diagnosis of primary liver cancerEarly diagnosis of hepatocellular carcinoma
Early diagnosis of hepatocellular carcinoma
Early diagnosis of primary liver cancer (PLC, hereafter referred to as liver cancer) is crucial. From 1970s to 1980s, the early diagnosis of hepatocellular carcinoma has been greatly facilitated by the gradual popularization and wide application of serum alpha-fetoprotein (AFP), real-time ultrasonography and CT. Since the early diagnosis rate has significantly increased, the surgical resection rate has increased and the prognosis has been significantly improved. The diagnosis of liver cancer, especially the early diagnosis, is the key to clinical treatment and prognosis.
In terms of early diagnosis, full attention should be paid to the background of liver disease of patients. In China, 95% of liver cancer patients have background of hepatitis B virus (HBV) infection, 10% have background of hepatitis C virus (HCV) infection, and some patients have overlapping HBV and HCV infection.
Special attention should be paid to the following risk groups: middle-aged and elderly men with high HBV load, HCV-infected patients, patients with overlapping HBV and HCV infection, alcoholics, patients with combined diabetes mellitus, and patients with family history of liver cancer. After the age of 35-40, these patients should be screened regularly every 6 months (including serum AFP test and liver ultrasound); when there is an elevated AFP or “occupying lesion” in the liver area, they should enter the diagnostic process immediately and be closely observed to make early diagnosis.
Laboratory diagnosis methods of liver cancer
At present, the qualitative diagnosis of hepatocellular carcinoma in China is still based on the detection of serum AFP, which should be highly regarded.
1. in China, more than 60% of liver cancer cases have serum AFP>400μg/L.
2. there are no other tumor markers with specificity comparable to AFP.
3.AFP detection is less dependent on imaging equipment and new technology.
Diagnostic imaging methods of liver cancer
In recent years, the progress of medical imaging examination methods is obvious, which provides a reliable basis for the clinical “four determinations” (localization, characterization, quantification and regularity) of liver cancer and the formulation of treatment plans.
Ultrasound examination
Ultrasound examination is non-invasive and has no adverse effects on human tissues. It is simple, intuitive, accurate, inexpensive, convenient, non-invasive and widely used for the screening and post-treatment follow-up of liver cancer.
Real-time ultrasonography has important clinical value for the differential diagnosis of small hepatocellular carcinoma, and is often used for early detection and diagnosis of hepatocellular carcinoma, and is a good reference for the differential diagnosis of hepatocellular carcinoma from hepatic cysts and hepatic hemangioma, while intraoperative ultrasound probes directly on the surface of the liver after opening, avoiding ultrasound attenuation and interference from the abdominal wall and ribs, and can detect small intrahepatic lesions that are not detected by preoperative CT and ultrasound. However, ultrasound examination is susceptible to the experience, technique and meticulousness of the examiner.
Multilayer spiral CT
CT has much higher resolution than ultrasound, and its image is clear and stable, which can reflect the characteristics of liver cancer comprehensively and objectively, and is used for routine diagnostic examination and post-treatment follow-up examination of liver cancer.
CT has the following advantages: CT enhanced scan can clearly show the size, number, shape, location, boundary, richness of blood supply of tumor and the relationship with intrahepatic ducts of liver cancer; it has important diagnostic value for whether there are cancer clots in portal vein, hepatic vein and inferior vena cava, whether there are metastases in hilar and abdominal lymph nodes, and whether liver cancer invades adjacent tissues and organs; it can also show the shape of liver, size of spleen and whether there is ascites. Therefore, CT has become an important routine tool for liver cancer diagnosis. In particular, CT dynamic enhancement scan can significantly improve the detection rate of small liver cancer; CT scan after 3-4 weeks of iodine oil embolization of hepatic artery can also effectively detect small liver cancer lesions.
Magnetic resonance imaging (MRI)
MRI has features such as high tissue resolution and multi-parameter and multi-directional imaging, and it has no radiation effect, so MRI is another efficient and non-invasive diagnostic method for liver cancer examination after CT.
The application of liver-specific MRI contrast agent can improve the detection rate of small hepatocellular carcinoma and help to differentiate hepatocellular carcinoma from focal hyperplastic nodules and hepatic adenoma; in addition, MRI has higher clinical value than CT for the follow-up of the efficacy of hepatic artery chemoembolization (TACE) in patients with hepatocellular carcinoma, and has unique features for the detection of small intrahepatic lesions, the condition of blood vessels, and the display of intra-tumor structures and their necrosis. MRI has unique features and can be an important supplement to CT.
Positron Emission Computed Tomography (PET)-CT
PET-CT is a functional molecular imaging system that integrates PET and CT. It can reflect the biochemical and metabolic information of liver occupancy by PET functional imaging, and can precisely locate the lesion by CT morphological imaging. It is also possible to understand the size and metabolic changes before and after tumor treatment.
Selective Hepatic Arteriography
Selective hepatic arteriogram is an invasive test, while chemotherapy and iodine oil embolization are also therapeutic, and can clearly show small lesions in the liver and their blood supply.
Links
Hepatocellular carcinoma “five large and six subtypes”.
1.Diffuse type, small cancer nodules are diffusely distributed throughout the liver.
2.Massive type, the tumor is larger than 10cm in diameter.
3.Mass type, the tumor diameter is between 5 and 10 cm, according to the number of masses and morphology, it is further divided into single mass, fusion mass and multi-mass type.
4.Nodular type, tumor body diameter between 3 to 5cm, according to the number and morphology of nodules, it can be further divided into single nodular type, fused nodular type and multi-nodular type.
5.Small cancer type: tumor diameter is less than 3cm.
dmondson-Steiner grading method.
Grade I: cancer cells are highly differentiated, with nuclear/quality ratio close to normal.
Grade II: cancer cells were moderately differentiated, but with increased nuclear/mass ratio and darker nuclear staining.
Grade III: cancer cells are poorly differentiated, with higher nuclear/mass ratio, marked nuclear heterogeneity, and frequent nuclear divisions.
Grade IV: cancer cells are the least differentiated, with less cytoplasm, dense nuclear chromatin staining, extremely irregular cell shape and loose arrangement.
(Note: Image provided by Cong Wenming, Department of Pathology, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University)
Pathological diagnosis of hepatocellular carcinoma
Pathological examination is the gold standard for the diagnosis of primary liver cancer, but special attention should still be paid to the combination with clinical. The pathological histology of hepatocellular carcinoma is mainly divided into three types: hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (ICC) and mixed hepatocellular carcinoma. Fibrous lamellar carcinoma is a special type of HCC, commonly seen in adolescents, mostly without cirrhosis, with slow growth and better prognosis.
In view of the differences between HCC and ICC in terms of pathogenesis, biological characteristics, clinical manifestations, treatment methods and prognosis, attention should be paid to differentiation and corresponding diagnosis and treatment norms should be formulated respectively. The main diagnostic bases are as follows.
1. HCC is mostly seen in a beam-cord arrangement, with polygonal cancer cells, eosinophilic cytoplasm, round nuclei, and blood sinusoids lining between the beams and cords, but there can also be a variety of cytologically and histologically specific types, such as the common pseudoglandular duct structure, which require careful differential diagnosis. Representative immunohistochemical staining: hepatocyte antigen (HepPar1) shows positive cytoplasm, polyclonal carcinoembryonic antigen (pCEA) shows positive cell membrane (capillary bile ducts), and CD34 shows diffuse positive microvasculature.
2.The general typing of HCC can refer to the classification of “five large and six subtypes” developed by the Chinese Hepatocellular Carcinoma Pathology Research Collaborative Group in 1979, and the degree of differentiation of cancer cells can refer to the Edmondson-Steiner four-grade classification.
3.ICC is mainly in glandular ductal arrangement, and the cancer cells are rectangular or low columnar in shape, with lightly stained or basophilic cytoplasm and abundant interstitial fibers, but there can be various cytological and histological special types, which require careful differential diagnosis. Representative immunohistochemical stains: cytokeratin 19 (CK19) and mucoglycoprotein-1 (MUC-1) show positive cytoplasm.
4.The general types of ICC can be divided into nodular, peritubular infiltrative and nodular infiltrative types, and the degree of cancer cell differentiation can be divided into good, moderate and poor.
5.Mixed hepatocellular carcinoma is the presence of both hepatocellular carcinoma and bile duct carcinoma in one hepatocellular carcinoma node, and the biological characteristics are between the two types.
Hepatocellular carcinoma is not exactly equivalent to the concept of early stage liver cancer. Some small hepatocellular carcinomas can have small metastases in early stage, and their surgical resection efficacy may not be very good; in addition, early stage hepatocellular carcinoma does not exactly mean that liver function is in a compensated state, nor does it mean that they are all resectable.
The pathological diagnosis report should include: tumor site, size, number, cellular and histological types, differentiation degree, vascular and envelope invasion, satellite and metastatic foci, as well as paracancerous liver tissue lesions. The report may also be accompanied by the results of immunohistochemistry and molecular markers related to drug-targeting molecules, biological behavior and prognosis of hepatocellular carcinoma for clinical reference.
Surgical treatment of primary liver cancer
Surgical treatment of primary liver cancer (PLC, hereafter referred to as hepatocellular carcinoma) includes hepatic resection and liver transplantation. The hepatic resection
The basic principles include
(i) Completeness: complete resection of the tumor with no residual tumor on the cut edge.
②Safety: maximum preservation of positive liver tissues and reduction of surgical mortality and surgical complication rate. The liver function reserve should be evaluated before surgery, usually using Child-Pugh classification to evaluate the liver parenchymal function and CT and/or magnetic resonance imaging (MRI) to calculate the residual liver volume.
Hepatectomy
Classification of liver resection methods
Liver resection methods include radical resection and palliative resection. Radical resection is defined as.
(i) the number of tumors does not exceed 2.
② absence of portal trunk and primary branches, common hepatic duct and primary branches, hepatic vein trunk and inferior vena cava cancer thrombus.
③ no intra- or extra-hepatic metastases, complete resection of tumors seen by the naked eye, and no residual cancer at the cut edge.
④No tumor residue is seen in postoperative imaging, and serum AFP is reduced to normal within 2 months of postoperative follow-up for those with positive preoperative alpha-fetoprotein (AFP).
Indications for surgical treatment of hepatocellular carcinoma
With the advancement of modern liver surgery technology, tumor size is not the key limiting factor for surgery. The efficacy of resection is not only related to the size and number of tumor, but also very closely related to liver function, degree of cirrhosis, tumor site, tumor boundary, presence of intact envelope and venous cancer thrombus.
Indications for hepatocellular carcinoma surgery promulgated by the Hepatology Group of the Chinese Society of Surgery
General condition of the patient (required condition): good general condition, no significant organic lesions of important organs such as heart, lung and kidney; normal liver function, or only mild impairment (Child-Pugh grade A), or liver function grading of grade B, recovered to grade A after short-term liver protection treatment; liver reserve function [such as indocyanine green 15-minute storage rate (ICGR15)] basically within the normal range. No unresectable extrahepatic metastatic tumors. Local lesions amenable to radical hepatectomy must meet the following conditions.
①single hepatocellular carcinoma with smooth surface, clear surrounding boundaries or pseudo-envelope formation, <30% of liver tissue destroyed by tumor, or >30% of liver tissue destroyed by tumor but significant compensatory enlargement of the tumor-free side of the liver up to more than 50% of the whole liver tissue.
② Multiple tumors with <3 nodules and confined to a segment or a lobe of the liver. Local lesions amenable to palliative hepatectomy must meet the following conditions.
①3 to 5 multiple tumors beyond half of the liver with multiple limited resections.
(ii) Tumors confined to two to three adjacent hepatic segments or hemihepatic, with significant compensatory enlargement of tumor-free liver tissue up to more than 50% of the whole liver.
③hepatocellular carcinoma in the central region of the liver (middle lobe or segment IV, V, VIII), with apparent compensatory enlargement of tumor-free liver tissue to more than 50% of the whole liver.
④ For those with lymph node metastasis in the hilar region, lymph node dissection or postoperative treatment should be performed at the same time of tumor removal.
(4) For those with lymph node metastasis in the hilum, lymph node dissection or postoperative treatment should be performed at the same time as resection of tumor.
(5) If the surrounding organs are invaded, they should be removed together. Palliative hepatectomy also involves the following conditions: hepatocellular carcinoma combined with portal vein thrombosis (PVTT) and/or vena cava thrombosis, hepatocellular carcinoma combined with bile duct thrombosis, hepatocellular carcinoma combined with cirrhotic portal hypertension, and resection of difficult-to-cut hepatocellular carcinoma. Each of these conditions has its corresponding indications for surgical treatment (Table 1). In addition, for hepatocellular carcinoma that is not suitable for palliative resection, palliative non-resective surgical treatment should be considered, such as intraoperative hepatic artery ligation and/or hepatic artery and portal vein cannulation chemotherapy. The treatment of microscopic intrahepatic lesions deserves attention. Some microscopic lesions are not detected by imaging or intraoperative exploration, resulting in a higher recurrence rate after hepatic resection. If incomplete resection is suspected, then postoperative hepatic artery chemoembolization (TACE) is the ideal choice, because in addition to the significance of treatment, it also has the significance of checking residual cancer foci. If there are residual cancer foci, prompt remedial measures should be taken. In addition, postoperative cases should be examined for hepatitis viral load [hepatitis B virus (HBV) DNA/hepatitis C virus (HCV) RNA] and, if indicated, antiviral therapy should be administered to reduce the possibility of recurrence of hepatocellular carcinoma.
Table 1 Indications for palliative liver resection for hepatocellular carcinoma
Liver transplantation
Liver transplantation selection criteria
Currently, about 4000 liver transplantations are performed in China every year, among which the proportion of liver cancer patients is as high as 40%. In China, liver transplantation for liver cancer is only used as a complementary treatment for patients who cannot be surgically resected, cannot be treated with radiofrequency, microwave and TACE, and whose liver function cannot be tolerated. Regarding the indications for liver transplantation, the international standards are mainly adopted by Milan (Milan) and University of California, San Francisco (UCSF) standards; while there is no unified standard in China, several units have proposed different standards, mainly Shanghai Fudan standard, Hangzhou standard and Chengdu standard. The requirements for the absence of large vessel invasion, lymph node metastasis and extrahepatic metastasis are relatively consistent among these standards, but the requirements for the size and number of tumors are different. China’s standards have expanded the scope of indications for liver transplantation for liver cancer, which can benefit more liver cancer patients from surgery and may be more in line with China’s national conditions and the actual situation of patients, but a relatively unified Chinese standard based on high level of evidence-based medical evidence has yet to be formed. Prevention of recurrence after liver transplantation It is generally believed that appropriate postoperative chemotherapy and antiviral therapy may reduce recurrence of liver cancer and improve survival, but further research is needed.
Choice of liver transplantation and hepatic resection
Surgical treatments are mainly hepatic resection and liver transplantation, and there is no uniform standard on how to choose them. It is generally believed that for limited hepatocellular carcinoma, liver resection should be preferred if the patient is not accompanied by cirrhosis; if combined with cirrhosis, liver function is decompensated (Child-Pugh grade C) and eligible for transplantation, liver transplantation should be preferred; for resectable limited hepatocellular carcinoma with good liver function compensation (Child-Pugh grade A), whether liver transplantation can be performed is more controversial. European experts support the preference for liver transplantation on the basis of the high recurrence rate of hepatic resection and the significantly better long-term survival and nonsurvival rates for liver transplant patients meeting Milan’s criteria than for hepatic resection patients. In the case of a particular patient, a comprehensive evaluation and analysis of the surgical plan is emphasized on a case-by-case basis. In addition, preoperative angiography should be performed for resectable hepatocellular carcinoma, even if the imaging presentation is limited resectable hepatocellular carcinoma, because it can detect lesions that cannot be detected by other imaging means and also clarify the presence of vascular invasion.
5.Interventional treatment of primary hepatocellular carcinoma
Applicable groups
1.Patients with middle and late stage primary liver cancer (PLC, hereinafter referred to as liver cancer) that cannot be surgically resected.
2.Patients who can be surgically resected but are unable or unwilling to undergo surgery due to other reasons (e.g. advanced age, severe cirrhosis, etc.).
For the above-mentioned patients, radiointerventional therapy can be the preferred method in non-surgical treatment.
Domestic clinical experience shows that radiointerventional therapy is more effective for giant hepatocellular carcinoma with relatively intact envelope and large hepatocellular carcinoma. For resectable hepatocellular carcinoma, the influencing factors for preferring surgical resection or interventional treatment include.
① serum alpha-fetoprotein (AFP) level.
②whether the tumor lesion has intact envelope and clear boundary.
③The presence or absence of cancer thrombus in portal vein.
Indications and contraindications
Both hepatic artery chemotherapy (HAI) and hepatic artery embolization (HAE) have clear indications and contraindications (Table 1); chemoembolization (TACE) is very important, and giving HAI alone is not enough.
Table 1 Indications and contraindications for hepatic artery chemotherapy (HAI) and hepatic artery embolization (HAE)
Operation procedures and points
1, hepatic arteriography: using the Seldinger (Seldinger) method, transarterial puncture cannulation, catheter placed in the abdominal trunk or common hepatic artery imaging, imaging image acquisition should include the arterial phase, parenchymal phase and venous phase.
2. Perfusion chemotherapy: After careful analysis of the imaging performance, the site, size, number and blood supplying artery of the tumor are clarified, super-selective intubation into the blood supplying artery of the tumor is performed to give perfusion chemotherapy.
3.hepatic artery embolization: suitable embolization agent should be selected. Generally, super liquefied iodine oil and chemotherapeutic drugs should be fully mixed into emulsion, and the amount of iodine oil should be flexible according to the size of tumor, blood supply and the number of tumor blood supplying arteries.
TACE for hepatocellular carcinoma places great emphasis on super-selective intubation. In the past, super-selective intubation was only emphasized for small hepatocellular carcinoma, but now it is especially emphasized for all hepatocellular carcinomas, except for multiple nodes, super-selective intubation should be used. For large hepatocellular carcinoma, super-selective intubation is more beneficial to control tumor growth and protect normal liver tissue.
Follow-up and treatment interval
The follow-up period is usually from 35 days to 3 months after the intervention, and in principle, it should last at least 3 weeks from the time the patient recovers from the intervention. The frequency of interventional treatment depends on the results of follow-up: if the liver tumor lesion is densely deposited with iodine oil and the tumor tissue is necrotic without new lesions or new progression one month after the intervention, interventional treatment should be withheld. The treatment interval should be extended as much as possible. The density can be increased in the first few treatments, after that, the treatment interval should be prolonged without tumor progression to ensure the recovery of liver function. During the treatment interval, the survival of liver tumor can be evaluated using magnetic resonance imaging (MRI) dynamic enhancement scans to determine the need for re-interventional treatment.
Hepatic artery chemoembolization (TACE)-based “individualized” plan
1. Second-stage resection after hepatocellular carcinoma shrinkage: After the interventional treatment of large hepatocellular carcinoma has shrunk significantly, surgical operation can be adopted.
2.Prophylactic intervention after hepatocellular carcinoma: Since most hepatocellular carcinomas occur on the basis of cirrhosis, most cases are multifocal, and some small lesions may not be detected intraoperatively, for patients suspected of non-radical resection, prophylactic infusion chemoembolization is recommended about 40 days after surgery.
3.Treatment of portal vein cancer embolism and inferior vena cava cancer embolism: stent placement and radiotherapy can be used. Regarding inferior vena cava cancer embolism, if it is caused by tumor enlargement and compression and the patient is asymptomatic, no stent can be placed and only TACE can be used to observe whether the tumor can shrink.
4. The TACE-based individualized program also involves the treatment of ruptured hepatic tumor with bleeding, treatment of hepatocellular carcinoma with lung metastasis, TACE combined with ablation, radiotherapy, gene and targeted therapy, etc.
In conclusion, the active use of TACE-based comprehensive treatment measures should be emphasized in order to obtain good curative effect.