Primary liver cancer is one of the most common malignant tumors in clinical practice, 90% of which are hepatocellular carcinoma (HCC), and the other 10% are cholangiocellular carcinoma and mixed hepatocellular-cholangiocellular carcinoma. China is a high incidence area of liver cancer, and the annual number of new cases of liver cancer in mainland China accounts for 43% of the global new cases and 45% of the deaths. Since the 1990s, liver cancer has risen to become the second cancer killer in China, and it is more common in men aged 40-49 years. At present, it is thought to be related to hepatitis B, hepatitis C, aflatoxin, drinking sewage, parasitic infection, etc. Clinical manifestations 1. Medical history: viral hepatitis (90%), cirrhosis, alcoholism, consumption of moldy food, drinking water pollution, family history, high incidence area, etc., and the disease progresses rapidly. 2.Symptoms: early stage may have no conscious symptoms, middle and late stage may show liver pain, poor performance, weakness, emaciation, abdominal distension, fever, jaundice, etc. 3.Signs: When the tumor is large, epigastric mass can be palpated, irregular, hard, and the surface is not smooth; in the late stage, anemia, jaundice, ascites, etc., and in case of rupture and bleeding, there can be signs of acute peritonitis and hemorrhagic shock. 4.Paraneoplastic syndrome: caused by ectopic hormones made and secreted by liver cancer tissue itself, such as hypoglycemia (10-30%), erythrocytosis (2-10%), hypercalcemia, hyperfibrinogenemia, etc. Other paraneoplastic syndromes include hyperlipidemia, thrombocythemia, dermal porphyria, hyperglycemia, etc. Laboratory data: (1) Routine blood tests may show hypersplenism. (2) Specific tests: alpha-fetoprotein (AFP): positive by convective electrophoresis or >400mg/ml for four weeks or >200mg/ml for eight weeks by exclusion of pregnancy, active liver disease and germinal gland embryonic-derived tumor can confirm the diagnosis of primary hepatocellular carcinoma. Increased alkaline phosphatase (ALP) and elevated r-glutamyl transpeptidase (r-GT) without jaundice. In addition, elevated 5-nucleoglycerate diphosphatase isoenzyme V, increased α-antitrypsin (α-AT), and abnormal prothrombin >250 μg/L are also significant. (3) Liver function and viral hepatitis antigen antibody system examination: abnormal liver function and positive hepatitis B and C markers. (1) Ultrasonography: It can show the size, shape, location, tumor blood flow and the presence of cancer thrombus in the hepatic vein or portal vein, etc. Its diagnostic rate can reach more than 90%, and it can detect lesions of 1.5 cm or smaller in diameter. Small hepatocellular carcinoma (<3cm) may appear as hypoechoic, while larger hepatocellular carcinoma may appear as isoechoic or hyperechoic or mixed echogenicity, and some of them can be seen as peripheral echogenic halo. Ultrasonography can show the typical "fast-in-fast-out" performance of strong echogenicity with uniform or heterogeneous enhancement in the arterial phase and exit in the portal phase or parenchymal phase, as well as the characteristics of trophoblastic arteries and neovascularization that encircle and enter the tumor in a spherical shape. (2) CT examination: It can detect early hepatocellular carcinoma of 2.0 cm in diameter, and the application of enhanced scan can improve the resolution, and the diagnostic rate of hepatocellular carcinoma is over 90%. Most hepatocellular carcinomas show low density in plain scan, with low detection rate (20%-40%); enhanced scan shows "fast in and fast out" like arterial (A) phase with rapid enhancement (86% detection rate); portal vein phase mostly shows low density, sometimes with small ring-like enhancement (67% detection rate); delayed The mean sensitivity of the three scans was 89% and the specificity was 99%. Delayed iodine oil contrast CT examination shows the area of iodine oil accumulation after 1-3 weeks. (3) MRI: On T1-weighted images, low signal accounted for 2/3 and high signal accounted for 1/3; on T2-weighted images, the majority of hepatocellular carcinoma showed inhomogeneous high signal areas; T1-weighted images showed moderate signal intensity and T2-weighted images showed high signal intensity in case of cancer thrombosis; on contrast images, primary hepatocellular carcinoma showed high signal areas. (4) Selective hepatic arteriography and digital subtraction technique (DSA): It is a sensitive examination method that can show hepatocellular carcinoma within lcm in diameter, but it is an invasive examination and is not a routine examination item. The arterial phase can show the tumor vascular proliferation disorder, and the capillary phase shows the tumor mass staining which is the characteristic manifestation of small hepatocellular carcinoma; the arterial phase shows the contrast agent accumulation in the tumor and delayed emptying which shows the "tumor lake" image, and the arterial phase shows the portal vein shadow which indicates the arteriovenous fistula. Clinical classification 1.Diffuse type: The cancer nodules are small and diffusely distributed. 2.Mass type: the diameter of cancer tumor is more than 5M, of which more than 10M is the giant mass type. 3.Nodular type: cancer nodules less than 5M in diameter, which can be further divided into: (1) Single nodule type: single cancer nodule with clear boundary and envelope. (2) Fusion nodule type: irregular boundary and scattered surrounding satellite nodules. (3) Multi-nodular type: scattered in all parts of the liver with clear or irregular borders. 4.Small carcinoma type: single carcinoma nodule diameter is less than 3M, or the sum of two adjacent carcinoma nodules diameter is less than 3M, with clear boundary and often obvious envelope. Clinical staging Ⅰa: single tumor with maximal diameter ≤3cm, no cancer embolus, abdominal lymph nodes and distant metastasis; liver function classification Child A. Ⅰb: single or two tumors with maximal diameter sum ≤5cm, in half liver, no cancer embolus, abdominal lymph nodes and distant metastasis; liver function classification Child A. Ⅱa: single or two tumors with maximal diameter sum ≤10cm, in half liver or two tumors The maximum diameter of a single tumor or the sum of two tumors ≤ 5 cm, in the left and right hemispheres, without cancerous thrombus, abdominal lymph nodes and distant metastases; liver function classification Child A. IIb: The maximum diameter of a single tumor or the sum of two tumors > 10 cm, in the hemispheres or the sum of two tumors > 5 cm, in the left and right hemispheres, or multiple tumors without cancerous thrombus, abdominal lymph nodes and distant metastases; liver function classification Child A. Tumor Regardless of tumor condition, there is cancer embolism in portal vein branch, hepatic vein or bile duct and/or liver function grade Child B. IIIa: Regardless of tumor condition, there is cancer embolism in portal vein trunk or inferior vena cava, abdominal lymph nodes or distant metastasis; liver function grade Child A or B. IIIb: Regardless of tumor condition, cancer embolism and metastasis; liver function grade Child C. Treatment principle: Surgery Excision is the first choice of PHC treatment, and radical resection is still the most effective means to improve long-term survival; single treatment method is difficult to achieve the best results, and comprehensive treatment is needed; local treatment means is an essential supplement to surgical resection, and the above three principles have become a consensus. 1.Surgical treatment: Suitable for clear diagnosis, no obvious jaundice, ascites or unresectable distant metastasis; still good liver function compensation, Child-Pugh grade A; good heart, lung and kidney function. Surgery: (1) Radical resection: Applicable to those whose tumor is confined to one lobe or half of the liver or to the hypertrophy of liver tissue on the tumor-free side, and it is estimated that the remaining liver tissue can be completely compensated after resection. The resection area is required to be at least 2 cm above the tumor margin. It can be a regular lobectomy or segmental resection, or irregular hepatectomy. The amount of liver resection should not exceed 70% for those with normal liver function and 50% for those with moderate cirrhosis, and those who cannot reach Child-Pugh grade A even after active treatment of abnormal liver function should not undergo hepatectomy. (2) Palliative surgery: It is suitable for patients with multiple and scattered hepatocellular carcinoma and distant metastases but can be resected. The main methods include local resection of hepatocellular carcinoma, combined metastasis resection, hepatic artery ligation and cannulation, portal vein and bile duct cancer embolism removal, etc., which can prolong the survival and reduce the symptoms. (3) Local ablation therapy: open and laparoscopic local ablation therapy has the advantages of more accurate positioning, effective protection of surrounding organs and less chance of damage. It is suitable for patients with small lesions (<5cm) close to the top of diaphragm, other important organs of abdominal cavity, gallbladder, etc., which are contraindicated for surgical resection, or patients with multiple tumors (<4), scattered locations, or small residual lesions of the main tumor that have been removed by surgery, or lesions that cannot be removed by surgery. ①Chemical ablation therapy: Chemical agents such as anhydrous ethanol, 15%~50% acetic acid, high temperature (60℃) distilled water, high temperature saline, high temperature chemotherapeutic drugs are injected into the tumor to dehydrate local cells, coagulate proteins and occlude blood vessels, so as to achieve the treatment purpose. ②Thermal ablation technology: Through various technologies, the local temperature of tumor is increased to more than 40℃ and maintained for a period of time to cause local cell thermal coagulation and necrosis. Currently, radiofrequency ablation (RFA), laser thermal ablation (LTA), high-energy focused ultrasound (HIFU ), microwave thermal coagulation therapy (WCT), etc. are commonly used in clinical practice, which has been developed to apply the third-generation hollow condensing electrode needle, and the ablation range can reach 7cm in diameter, which can achieve the same effect as surgical resection for small hepatocellular carcinoma, especially (<3cm). (4) Liver transplantation: At present, there is no unified indication standard, but the Milan standard or the UCSF standard are widely used internationally. Some people in China are also implementing the Shanghai standard and Hangzhou standard. The patient's systemic condition is required to meet the following basic conditions: no significant organic lesions of heart, lung, kidney and other important organs; abnormal liver function with Child-Pugh grade C, or long-term grade B; no extra-hepatic metastatic tumors. (5) Bioimmunotherapy: After surgery, chemotherapy and radiotherapy, bioimmunotherapy has become the fourth major therapeutic measure for tumor treatment. Currently, tumor vaccines, lymphokine-activated killer cells (LAK) and tumor-infiltrating lymphocytes, cytokines such as interferon, IL2 and TNF, thymidine and thymopentapeptide are commonly used in clinical practice, but their efficacy is difficult to determine. Genetically engineered vaccines, dendritic cell vaccines, peptide vaccines, nucleic acid vaccines, and targeted gene therapy for liver cancer are the hot spots of research, but their clinical application is still in need of time. Vascular growth inhibitors can interfere with or block the formation of tumor neovascularization, and TNP-470 and other drugs have been used in clinical trials. (6) Traditional Chinese medicine treatment: It is a part of comprehensive treatment for liver cancer, which can be combined with other therapeutic measures and is applicable to all types of liver cancer treatment. The treatment is to soothe the liver and regulate the qi, strengthen the essence, detoxify the dampness and activate the blood circulation. (7) Hormone therapy: Recent studies have found that hepatocellular carcinoma cells can express estrogen receptors, therefore, some people apply triamcinolone or add oxytetracycline to treat hepatocellular carcinoma, but the exact efficacy needs to be further confirmed. (8) Radioisotope therapy: It is an emerging non-surgical treatment method, in which radionuclides are implanted into the tumor through hepatic artery injection, B-ultrasound or CT-guided puncture injection or surgical implantation, which has the advantages of simple operation, less trauma, less toxicity and less impact on surrounding liver tissues. Currently, the commonly used radioisotopes are 131I, 90Y, 188Re, etc. The overall prognosis is poor. Without treatment, the survival period is usually 3-6 months after the onset of symptoms; the surgical resection rate after diagnosis is less than 30%, and the overall 5-year survival rate after hepatectomy is 30%-50%, while small hepatocellular carcinoma can reach 40%-80%, and palliative resection is only 12.5%, and the recurrence rate 5 years after hepatectomy is reported by multicenter to be more than 60%. The overall 5-year survival rate after liver transplantation for hepatocellular carcinoma is 20%-30%, and it has been reported that the 4-year survival rate can reach 85% if the Milan criteria are followed. The efficiency of chemotherapy is generally about 10%, not more than 20%, and the survival rate of 5 years is rarely seen with drug therapy alone.