1. What is liver cancer?
When we talk about liver cancer, we mainly refer to primary liver cancer (PLC). It is a common malignant tumor. It is a common malignant tumor with insidious onset and rapid progression, and most patients are already in the middle and late stages when diagnosed, and the prognosis is often poor.
Primary liver cancer mainly includes hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (ICC) and mixed hepatocellular-cholangiocarcinoma, of which HCC accounts for more than 90% of the pathological types. This article focuses on transarterial chemoembolization (TACE) for mid- to late-stage HCC.
2. How to stage hepatocellular carcinoma and what is intermediate and advanced stage hepatocellular carcinoma?
The most commonly used international staging of liver cancer is Barcelona staging (BCLC), which has guiding significance for clinical treatment selection (see Table 1).
BCLC staging comprehensively considers tumor, liver function (Child classification) and systemic conditions (PS score), links to treatment principles, and is supported by high-level evidence of evidence-based medicine, and is now widely adopted worldwide.
3.What does liver function (Child classification) include?
The concept of liver function classification was first introduced by Child in 1954. On this basis, Child-Turcotte proposed the Child-Turcotte classification in 1964 to estimate liver function status from five dimensions: serum bilirubin, plasma albumin, ascites, hepatic encephalopathy and nutrition, but it has the following defects: 1, nutritional status and ascites are non-quantitative indicators, which are influenced by subjective factors and are more difficult to evaluate; 2, albumin, ascites and nutritional status are associated, and it is suspected of duplication to list them separately; 3, the use of the same criteria is not comprehensive and does not take into account different etiologies, such as biliary hepatic sclerosis, post-hepatitis hepatic sclerosis and alcoholic hepatic sclerosis are not reflected differently in Child grading; 4, the lack of prothrombin time is an important indicator affecting the prognosis of surgery, which is not reflected in this grading; 5, plasma albumin and serum bilirubin cannot reflect the changes of liver function in a timely manner In 1973, Pugh proposed the Child-Pugh grading on the basis of the Child grading. In it, the prolonged prothrombin time was used instead of nutritional status, and the comprehensive score was used to evaluate liver function; the degree of hepatic encephalopathy was also staged; biliary hepatic steatosis was singled out. In this way, Child-Pugh grading uses the scoring method to estimate the status of liver function, so that the original independent indicators can be considered comprehensively, thus not being influenced by one indicator too much, and partially overcoming the shortcomings of Child-Turcotte grading. It is a commonly used clinical method for grading liver function (see Table 2).
4.What does the PS score include?
PS score refers to the evaluation of the patient’s physical activity status (Performance Status), that is, the patient’s physical strength to understand his or her general health status and ability to tolerate treatment. The main contents are as follows.
Score 0: The mobility is completely normal and does not differ from the mobility before the onset of the disease.
Score 1: Able to walk freely and engage in light physical activities, including general housework or office work, but unable to engage in heavier physical activities.
Score 2: Able to walk freely and take care of oneself, but has lost the ability to work, and can get up and move around at least half of the daytime.
3 points: only partially able to take care of himself/herself, bedridden or wheelchair-bound for more than half of the daytime.
4 points: bedridden, unable to take care of himself/herself.
5 points: Death.
5.Can middle and late stage liver cancer be treated? Is it still worth treating?
Since it is difficult to cure middle and late stage liver cancer, there was a wrong view in the past that middle and late stage liver cancer cannot be cured, so it is untreatable and not worthy of treatment. However, with the development of medicine and the progress of the times, more and more therapeutic means have been applied to liver cancer patients in an integrated way, and middle and advanced stage liver cancer can be treated completely and has good curative effects.
Clinical research proves that if patients with intermediate to late stage liver cancer are not treated and allowed to develop, they will soon progress to end-stage liver cancer and their survival period is less than 3 months. If a comprehensive treatment based on interventional therapy and supplemented by other methods is carried out, about 50% of patients with mid-stage liver cancer can survive for more than 3 years; for patients with advanced liver cancer, there is a 50% chance that their survival period can exceed 1 year.
At the same time, the concept of tumor treatment has been constantly updated. Currently, it is believed that the main therapeutic goals of middle and late stage liver cancer are to control tumor progression, prolong patient’s survival and improve life quality. Taking interventional surgery as an example, it is less invasive, has quick recovery after surgery, and has little impact on life and work, which can significantly improve patients’ quality of life. Therefore, for patients with middle and advanced stage liver cancer, treatment is not only worthwhile, but also necessary.
6.How to treat mid-to-late stage liver cancer?
At present, only a very small proportion of patients with intermediate and advanced liver cancer are suitable for surgical treatment, and the recurrence and metastasis rate after surgical resection of intermediate and advanced liver cancer is relatively high, which is related to the possible existence of microscopic disseminated foci or tumor multicenter occurrence before surgery. Moreover, once the tumors of these patients recur, they often progress rapidly and seriously endanger patients’ lives. Therefore, for patients with intermediate and advanced hepatocellular carcinoma, transarterial chemoembolization (TACE)-based interventional therapy is currently recognized internationally and mainly recommended.
7.What is transarterial chemoembolization (TACE) for hepatocellular carcinoma?
It is a kind of interventional treatment for hepatocellular carcinoma. It usually refers to puncturing the femoral artery at the root of the patient’s thigh, inserting a fine catheter into it, and sending the catheter to the tumor site in the liver through the fluoroscopic guidance of digital subtraction angiography (DSA) machine.
TACE can not only kill tumor cells directly, but also block the blood supply to the tumor, so that the tumor can be starved to death without nutrition, which is currently the first choice of treatment for middle and late stage liver cancer at home and abroad.
8.What patients are suitable for interventional treatment?
Patients who are suitable for interventional treatment are
(1) Patients with intermediate and advanced primary liver cancer who 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.).
(3) small hepatocellular carcinoma, but not suitable for or unwilling to undergo surgery, local radiofrequency or microwave ablation treatment.
9.What are the main roles of hepatocellular carcinoma interventional therapy?
(1) Treatment of intermediate and advanced hepatocellular carcinoma that cannot be surgically resected.
(2) Application of interventional therapy before open liver tumor resection can reduce tumor volume and facilitate second-stage surgical resection, while the number of lesions can be clarified.
(3) control local pain and bleeding as well as embolization of arteriovenous impotence.
(4) For some patients with large tumors and high chance of recurrence after surgery, postoperative prophylactic intervention can be done about 1 month after surgery to kill possible residual active lesions and reduce the chance of recurrence.
10.What conditions are not suitable for intervention?
If the patient is combined with serious heart, brain, lung and other important organ diseases, liver function grade C or PS score greater than or equal to 3, intervention is not suitable.
11.Can we intervene again after relapse?
After TACE treatment, the lesion is stable and there is no clear active lesion, regular review is sufficient. If there is a relapse, or if there is residual activity of the lesion after treatment, or if the lesion has progressed, TACE treatment should be repeated, and the interval between two TACE treatments can be 6-8 weeks, or the treatment interval can be extended appropriately depending on the actual situation.