As early as 1998, I wrote an article in the Chinese Journal of Hepatobiliary Surgery with the title “Several issues that should be noted in the diagnosis and treatment of hepatocellular carcinoma at the present stage in China”, proposing some questionable academic tendencies in the diagnosis and treatment of liver cancer at that time. More than ten years have passed, the diagnosis and treatment of liver cancer have made great academic progress. However, there are still many misconceptions in the minds of liver cancer patients and their families, which affect the treatment effect of liver cancer and the further improvement of liver cancer treatment level in China. These misconceptions mainly include the following aspects.
I. Treating “liver cancer like” as liver cancer
There should be a gold standard for the diagnosis of liver cancer, which should be 100% certain, and usually we regard pathological diagnosis as the gold standard for the diagnosis of liver cancer.
Of course, it is not the only way to diagnose and treat liver cancer with the gold standard of pathological diagnosis. In fact, the diagnostic rate of liver cancer by common clinical diagnostic tools is high, such as ultrasound, CT and MRI for liver cancer above 3 cm is about 90%, and if these tests are combined with relevant clinical information, the diagnostic rate for liver cancer above 3 cm should be more than 95% or even higher. Therefore, for liver cancer, with the help of complete clinical data, comprehensive imaging examinations and scientific analysis, it is not difficult to make a clear diagnosis.
The problem often lies in those nodular lesions of the liver that are not hepatocellular carcinoma, such as hepatic adenoma, hemangioma, and focal fatty deposits. These benign nodular lesions of the liver look like liver cancer (nodular) and sometimes resemble liver cancer on imaging, and are easily misdiagnosed as liver cancer.
It is worth mentioning that due to the many levels of medical units in China, there is a big difference in the level of clinical diagnosis. It is not uncommon to misdiagnose benign liver lesions that “look like liver cancer” as liver cancer, and this problem is especially prominent in primary care hospitals due to the experience of doctors and the quality of diagnostic imaging instruments.
We once admitted a 40-year-old male patient who was originally a fatty liver but was misdiagnosed as a huge hepatocellular carcinoma by the local hospital and was treated with interventional embolization several times. Another male patient, 32 years old, was found to have cirrhosis of the liver for 3 years, and ultrasound revealed an occupying lesion in the right liver, with a lesion about 5 cm in size. He was diagnosed with hepatocellular carcinoma at the local hospital and was prepared for interventional treatment. As the patient and family members had a desire for further consultation, they came to our hospital for further treatment. We took into account the inability to confirm the diagnosis of hepatocellular carcinoma and, moreover, the poor condition of the liver and the degree of cirrhosis and portal hypertension. Instead of interventional embolization, we opted for a surgical exploration of a diagnostic nature. A small incision was first made and some of the tissue of the suspected lesion was taken, which was diagnosed as benign tumor by pathological examination. Local excision treatment was given. The postoperative recovery was smooth.
Interventional treatment for benign tumors of the liver should be avoided as much as possible, and should be contraindicated if the degree of cirrhosis is severe. In this case, if the patient had hastily undergone interventional embolization according to the protocol of the local hospital, the liver function would have further deteriorated, and the consequences could be imagined. Here, we remind our doctors, patients and families not to treat “liver cancer like” as liver cancer.
Blindly copy the successful experience of other patients
Patients with liver cancer usually have to ask around about other patients with liver cancer, especially those with good results, where they were treated and what treatments they used. What treatment methods were used? etc. It is common and desirable to learn from other patients’ successful experience, but it is fine to learn from them, but never to copy them.
Scientifically speaking, patients with liver cancer are often very different from each other. Not only the size, location and differentiation of liver cancer are different, but also the age and liver function reserve of patients are different, plus the economic situation of patients are obviously different.
There is a Western proverb that “one man’s food may be another man’s poison”, which is an appropriate analogy for the choice of liver cancer treatment modality. Patients with liver cancer should choose the most appropriate treatment according to their individual conditions, and should not copy the successful treatment plans of others. It is often counterproductive to copy others’ successful treatment plans.
The best treatment plan for the patient is always with the doctor! This means that the best treatment plan should be developed by the doctor through a comprehensive analysis and judgment of all aspects of the patient’s condition. There are many factors that influence the doctor to formulate the treatment, usually including the following aspects.
1.Location of liver cancerThe location of liver cancer is the first element that affects the treatment plan. From the location of liver cancer, doctors can initially obtain several levels of judgment.
2.Can it be removed If liver cancer grows in the peripheral zone, it is easy to be removed and should be preferred to be removed; if liver cancer grows in the central area, it is unwise to pursue removal.
3.Whether it is worth to resect if the liver cancer is located in the central area, even if it can be resected, more normal liver tissues need to be removed while the liver cancer can be resected, and such resection is not worthwhile.
4.Ease and difficulty of resection Although all liver cancers are resectable, the ease and difficulty of resection are not obviously different. By carefully studying the location of hepatocellular carcinoma and its relationship with surrounding blood vessels, the ease of resection can be easily deduced. Like other malignant tumors, the treatment of hepatocellular carcinoma adopts comprehensive treatment, including surgical resection and other surgical treatment if it cannot be resected.
5.Size of liver cancer Besides the location of liver cancer, the size of liver cancer is another important factor that affects the treatment plan of doctors. Even if the tumor can be resected, due to the large size of the tumor, doctors have to remove the tumor along the edge of the tumor, which largely affects the long-term outcome. The prevailing view is that for resectable liver cancer, if it cannot be guaranteed to be removed 2 cm away from the liver cancer, then the surgical resection plan should be cautious.
6. Differentiation degree of liver cancer The differentiation degree of liver cancer is also an important factor influencing the doctor to make the surgical plan. For liver cancer with high or higher differentiation degree, doctors prefer surgical resection; if the differentiation degree is poor, surgical resection should be carefully chosen.
Strictly speaking, doctors cannot know exactly the differentiation degree of liver cancer cells before surgery, which requires putting the surgical specimen under microscope for pathologists to examine. However, doctors can make a general judgment on the differentiation degree of liver cancer by the following aspects.
Cancer foci have envelope. The presence of envelope is an important sign of high degree of differentiation.
The size of the cancer foci. The general rule is that the smaller the liver cancer foci, the better the degree of differentiation.
The growth pattern of liver cancer. If hepatocellular carcinoma shows swelling growth, it indicates good differentiation; if hepatocellular carcinoma shows infiltrative growth, it indicates poor differentiation.
The presence or absence of satellite foci or metastatic foci. Satellite foci or metastatic foci are important signs of low differentiation, high malignancy and easy metastasis of liver cancer cells.
If the patient is suffering from heavy cardiovascular disease, lung disease, or diabetes, it is difficult for him to tolerate the surgical blow, and even if the liver cancer is easily resectable, it is not easy to choose surgical resection.
8. The treatment of liver cancer is like the decoration of a house, and the cost can be a bottomless pit. If the patient’s economic condition is poor, it is advisable to choose treatment options with small cost, less variables and easy to fix, such as percutaneous puncture radiofrequency treatment and interventional embolization treatment, the total cost of which can be easily fixed at RMB 20,000; and then percutaneous puncture anhydrous alcohol injection, the treatment cost can be controlled within RMB 5,000. If the patient’s economic condition is better, it is easy to choose the way of comprehensive treatment, such as for resectable liver cancer, radiofrequency treatment can be chosen first, followed by resection, and combined with post-surgical interventional therapy, and immunotherapy, such comprehensive treatment is easy to achieve more ideal treatment effect, but the cost is larger, basically above RMB 50,000.
Third, exaggerate the role of a single treatment means, ignore the comprehensive treatment
Before the invention of interventional embolization and local treatment, the main means of treating liver cancer was surgical resection. Therefore, in some people’s perception, the treatment of liver cancer is surgical treatment. With the rapid development of medical science and technology, the viewpoint of relying solely on surgical resection to treat cancer has long become obsolete, and the current standardized treatment for cancer is comprehensive treatment.
The treatment for liver cancer mainly includes surgical resection, local treatment such as radiofrequency ablation, interventional embolization, chemotherapy, bioimmunotherapy and so on. Each of these treatment modalities has its own strengths, indications and limitations. Surgery is the main means of liver cancer treatment, and the 5-year survival rate of small liver cancer is 60-70%. However, when removing large hepatocellular carcinoma, tiny cancer foci are easily left behind at the cutting edge, and it also has a greater negative impact on liver function, and complications such as recurrence of the section or liver insufficiency are likely to occur after surgery. Local treatment such as radiofrequency ablation has good ablation effect on smaller liver cancer lesions and has little impact on liver function; however, when the size of cancer lesions is large, there are often problems such as incomplete ablation. Although interventional embolization therapy has a good therapeutic effect on cancer foci and is especially suitable for larger tumors or multiple tumors, this method has a greater negative impact on liver function, and excessive treatment may easily cause complications such as liver dysfunction. Although chemotherapy is a systemic treatment, its selective inhibitory effect is not strong, and chemotherapeutic drugs often do not distinguish between “enemy and me” and are more toxic, so it is difficult to completely destroy cancer cells by using chemotherapy drugs alone. Traditional Chinese medicine has its advantages in mobilizing the function of internal organs of the body, improving the body’s ability to resist diseases and reducing the side effects of other treatments, but its ability to control tumors locally is poor. Biological immunotherapy belongs to the focus of tumor treatment research in the 21st century, but the existing biological immunotherapy methods can only work when the number of residual tumor cells is small.
Different treatment modalities should be preferred for different liver cancers, and for each liver cancer, there should be treatment measures corresponding to the patient’s comprehensive situation at different stages. No single treatment method can solve all the problems of liver cancer. The most important measure to further improve the long-term treatment effect of liver cancer is to organically combine the advantages of the above treatment methods, to formulate an accurate and effective comprehensive treatment plan, to take advantage of the strengths and avoid the weaknesses, and to make use of the advantages of various treatment methods to improve the curative effect. Patients and family members should fully understand the importance of comprehensive treatment and should not believe in any one treatment method.
Emphasis on “evil” and neglect of “helping the right”
Most primary liver cancers develop on the basis of hepatitis B, hepatitis C and cirrhosis. In the process of occurrence and development of liver cancer, patients are often accompanied by abnormal liver function. Surgery and interventional embolization of liver cancer can directly damage liver tissues and aggravate liver function abnormalities. If the protection of normal liver tissues is not taken into consideration while treating tumors, complications such as liver insufficiency often occur and it is difficult to obtain good results.
The relationship between “evil” and “supporting the right” has been clearly discussed by the ancient medical scholars in China. Unfortunately, in today’s medical practice, we are still repeatedly making the low-level mistake of “emphasizing the evil, but not supporting the right”. In the treatment of liver cancer, this is especially prominent. Let’s take interventional embolization therapy as an example.
In foreign countries, the amount of drugs used for chemotherapy and embolization treatment for patients with mid- to late-stage liver cancer is only 1/3 as weak as that in China, and the variety of drugs used is relatively single. In China, doctors and patients advocate “high dose” and “multiple varieties” of drugs in order to kill cancer cells to the greatest extent, and believe that the degree of liver cancer cell necrosis and treatment effect are directly proportional to the amount of chemotherapy drugs.
The results of the two different treatment ideas are also different: in foreign countries, the average survival rate of patients with mid- to late-stage liver cancer is over 70% in one year and over 50% in two years after diagnosis. In China, the majority of patients with intermediate to advanced liver cancer generally survive less than six months from diagnosis to death.
The “heavyweight” treatment has caused many patients’ remaining normal liver function to be damaged and their immunity to be reduced, and they eventually die due to liver failure. However, in the misconception of one-sided pursuit of killing cancer cells, even if the patient has nausea and vomiting, high fever and abdominal pain, both doctors and patients think it is normal.
It is reported that a major hospital in Guangzhou has followed up the death of more than 100 liver cancer patients and found that more than 40% of them died of liver failure, not “liver cancer” in the real sense. Therefore, both doctors and patients should change the misconception that “more drugs are more effective”. Doctors should minimize the side effects of treatment and protect the normal liver function of patients.
A 62-year-old male patient who had hepatitis B for more than 10 years was found to have cirrhotic portal hypertension for 5 years, and ultrasound and CT examinations both indicated an occupying lesion in the liver. Combined with the patient’s history of hepatitis B and the progressive increase in the concentration of alpha-fetoprotein in the blood, he was diagnosed with liver cancer. Considering the old age, poor liver function reserve and the site of liver cancer located in the center of liver parenchyma, interventional embolization treatment was chosen.
After embolization treatment, the patient’s liver function became significantly abnormal, jaundice continued to worsen, and significant ascites gradually appeared. Finally, he died of multi-system organ insufficiency due to liver insufficiency.
Before the advent of local therapeutic procedures such as radiofrequency therapy, this patient should be said to have been right in choosing interventional therapy.
The obvious impairment of liver function after interventional therapy and the gradual progress toward functional insufficiency are clearly related to the side effects of interventional embolization therapy.
V. Emphasis on treatment of hepatocellular carcinoma and neglect of treatment of portal hypertension
Hepatocellular carcinoma often occurs and develops on the basis of portal hypertension. When many patients discover liver cancer, portal hypertension has already reached a relatively serious level. At this time, the treatment of liver cancer should fully consider the general background of cirrhotic portal hypertension, and should fully understand the influence of various complications of portal hypertension on the efficacy of liver cancer surgery, otherwise, it will make the mistake of losing sight of the other.
For the treatment of patients with cirrhotic portal hypertension combined with hepatocellular carcinoma, liver transplantation should be considered first. This is because liver transplantation can solve the problem of liver cancer and completely cure cirrhotic portal hypertension at the same time. However, not all such patients have the opportunity to undergo liver transplantation, and factors such as the size of the liver cancer lesion and financial status have strong constraints on liver transplantation. After all, patients who are eligible or fortunate enough to undergo liver transplantation are still in the minority, and most patients will also receive general surgical treatment.
For the surgical treatment of such patients, the following principles should generally be followed.
1. Manage both hepatocellular carcinoma and portal hypertension We know that one of the main reasons for the occurrence of hepatocellular carcinoma in patients with portal hypertension is the combination of portal hypertension with more severe hypersplenism, significantly lowered white blood cells in the blood and reduced defense against cancer. If only hepatocellular carcinoma is treated without dealing with portal hypertension, then the hypersplenism will be further aggravated after surgery and the immunity against cancer will be further reduced. This will not only affect the implementation of chemotherapy, but also contribute to the recurrence of tumor.
2.Treating liver cancer mainly and solving portal hypertension as a supplement As mentioned above, the two aspects should be dealt with at the same time, but never be treated as equivalent. Because liver cancer is a more important factor that affects the survival time and quality of patients, when developing treatment plans, the treatment of liver cancer should be the main focus, supplemented by solving the problems related to portal hypertension. As for the treatment of liver cancer, we should strive to remove it if we can, and try to achieve complete treatment to ensure the long-term efficacy; as for the treatment of portal hypertension, we should “take it easy”, so that the patient’s life expectancy and quality of life will not be affected by the problem of portal hypertension during his lifetime.
3.The amount of trauma of treatment should not exceed the capacity of the liver to treat liver cancer and to solve the problem of portal hypertension. In other words, the treatment plan exceeds the reserve function of the liver, and a series of complications such as liver insufficiency will inevitably occur after the surgery, the consequences of which can be imagined.
Sixth, emphasis on the treatment of tumor, ignore the maintenance of quality of life
With the change of medical treatment mode, people have changed the viewpoint of simply pursuing survival days in the past, and pay more and more attention to the maintenance of patients’ quality of life in the process of disease treatment, and take the maintenance of quality of life as the main starting point and focus point in the formulation of surgical plan.
For patients with hepatocellular carcinoma, we should abstain from overtreatment. The so-called overtreatment means that the treatment given by physicians to patients exceeds the treatment needs of patients, which often results in unnecessary pain and damage to patients’ body.
Clinically, there are still many such cases. In order to pursue the maximum elimination of tumor, patients and their family members have to use comprehensive measures such as surgery, interventional embolization, chemotherapy and so on, and the liver cancer is satisfactorily controlled, but the ensuing complications of liver insufficiency such as jaundice, ascites, poor appetite, malnutrition and weakness make patients and their family members cry out in agony. The feeling of life is worse than death.
There are many reasons for overtreatment, some physicians are cognitively deficient or technically conditioned. However, in some developed countries, many physicians are driven by financial interests and use their skills to over-treat patients in order to obtain rebates or additional surgical fees.
Seven, the importance of “hospital fame”, light “specialist advantage”
A hospital’s “fame” is the result of years of accumulation, is a true reflection of the level of medical care and quality of service, is the epitome of the hospital’s comprehensive strength. Generally speaking, these famous general hospitals have higher level of various medical disciplines, and liver cancer patients can often get better treatment effect when they go to these hospitals.
However, it is biased to say that the most famous hospitals have the highest level of liver cancer treatment for the simple reason that a hospital’s fame is not “earned” by the level of liver cancer treatment. For example, Beijing Fu Wai Hospital is famous enough to have thousands of patients from all over the country waiting for surgery. But the hospital is a specialty hospital that specializes in heart disease, so it would be inappropriate if liver cancer patients also admired its fame and went there for treatment.
As a major specialty disease, liver cancer has long been highly valued by governments at all levels and the medical community, and many hospitals have set up liver disease treatment centers, with comprehensive treatment of liver cancer as the discipline’s goal of attack, and these specialist doctors, who devote their main energy to research to explore the rescue and treatment of liver diseases such as liver cancer, also have their main academic interest in the treatment of liver diseases. These doctors have more practical experience, more means of treatment, more peer exchanges, more sources of information and more experience, and in these specialties, it is easier for patients to get the latest treatment that is suitable for their individual conditions.
Ignore the role of psychotherapy
Tumor patients are physically and mentally challenged. They need the understanding and help from the society, family and medical personnel. Scientific and effective psychological treatment will not only enhance patients’ confidence to overcome the disease and improve their quality of life, but also, maximize their organism immunity.
In Chapters 5 and 22 of this book, we describe the psychological characteristics and coping skills of liver cancer patients respectively, in order to remind patients and their family members not to neglect psychotherapy as a “panacea” in the treatment of liver cancer.
9. Discriminatory view of the role of Chinese medicine in the treatment of liver cancer
Chinese medicine plays a very important role in the treatment of liver cancer. Chinese herbal medicines that benefit qi and nourish blood can promote the recovery of surgical patients; Chinese herbal medicines that relax the liver and strengthen the spleen can reduce the toxic side effects of radiotherapy and increase the therapeutic effect of radiotherapy. The combination of Chinese herbal medicine to support the righteousness and dispel the evil can reduce the symptoms of patients with advanced disease and increase their chances of long-term survival with tumors. However, we should not exaggerate the therapeutic effects of TCM, and we should not exaggerate the efficacy of individual treatment methods. The blind and massive application of “attacking poison with poison” and “activating blood circulation and removing blood stasis” in advanced liver cancer patients may lead to aggravation or even deterioration of the disease. For example, excessive application of “activating blood circulation and removing blood stasis” may lead to hemorrhage and induce liver coma. Therefore, only through the combination of disease identification and evidence identification, the combination of local and overall, the combination of Chinese medicine and Western medicine, can we achieve good results.
X. Blindly advocating liver transplantation
If the liver is cancerous, just replace it with another one. This is another misconception of liver cancer patients.
It is true that liver transplantation is indeed an effective means to treat liver cancer, which can not only effectively remove virus and cure cirrhosis and portal hypertension, but also, maximize the removal of liver cancer cells. Theoretically, liver transplantation is the ideal means to treat liver cancer in the context of cirrhosis.
However, liver transplantation for the treatment of liver cancer also has significant limitations. After liver transplantation, in order to prevent the new liver from being rejected by the organism, sufficient immunosuppressive drugs need to be applied to suppress the immune function of the organism. When the body’s immune function is suppressed, cancer cells that have metastasized to other parts of the body before surgery will grow rapidly, leading to the recurrence of liver cancer.
As we can see, liver transplantation is not suitable for all liver cancers, and only patients with liver cancer without extra-hepatic metastases are suitable for liver transplantation treatment. For those larger liver cancers with intravenous, pulmonary or other metastases, systemic recurrence occurs within 6 months after liver transplantation and death occurs within a short period of time. For such patients, liver transplantation should not be blindly advocated.
At the present stage in China, the misconceptions in the diagnosis and treatment of liver cancer are by no means the only ten aspects mentioned above, there are many more. Only because other misconceptions are not as common as the above points, limited to space, this article will not repeat them. If you are interested, please feel free to communicate with us in any form. We are always ready to communicate with you.