(I) Treatment principles.
Treatment of hepatocellular carcinoma is mainly divided into surgical treatment and non-surgical treatment. According to the patient’s physical condition, tumor site, invasion range and liver function, the existing treatment means are applied in a planned and reasonable manner, with the aim of maximizing the eradication, tumor control and cure rate, and improving the patient’s quality of life.
(II) Surgical treatment.
1. Principles of surgical treatment
Surgical treatment of hepatocellular carcinoma includes liver resection and liver transplantation. Its treatment principles are
(1) Completeness: complete resection of tumor and no residual tumor on the cutting edge;
(2) Safety: to preserve normal liver tissues as much as possible and to reduce surgical mortality and complications. The liver function reserve should be evaluated before surgery, usually using Child-Pugh classification to evaluate the liver parenchymal function. The goals of treatment: one is to cure, two is to prolong survival, and three is to reduce pain.
2. Hepatic resection is feasible in the following cases (indications for surgery)
(1) The patient’s general condition is good, and there is no obvious organomegaly of heart, lung, kidney and other important organs;
(2) normal liver function or only mild impairment (Child-Pugh grade A); or liver function grade B, recovered to grade A after short-term liver care treatment; or liver reserve function (such as ICGR15) within the normal range;
(3) No clear extrahepatic metastatic tumor;
(4) Single hepatocellular carcinoma with smooth surface, clear surrounding boundary or pseudo-envelope formation, <30% of liver tissue destroyed by tumor, or >30% of liver tissue destroyed by tumor, but obvious compensatory enlargement of the liver on the tumor-free side, reaching more than 50% of the whole liver tissue;
(5) Multiple tumors with <3 nodules confined to a segment or lobe of the liver;
For patients who meet the indications, surgical treatment is feasible. For hepatectomy with special location or greater surgical difficulty and risk (such as middle lobe resection and tumors near important blood vessels), it is recommended to transfer to higher level hospitals for treatment.
3.The following conditions should not be treated by hepatectomy (contraindication to surgery)
(1) Poor cardiopulmonary function or combined with other important organ system serious diseases, can not tolerate surgery;
(2) Severe cirrhosis of the liver, Child-Pugh class C;
(3)The presence of extra-hepatic metastasis.
(3) Non-surgical treatment of hepatocellular carcinoma.
Although surgery is the preferred treatment for primary liver cancer, however, only about 20% of patients are suitable for surgery, and most of them are already in the middle and late stages at the time of diagnosis and have lost the opportunity of surgery. Therefore, the use of non-surgical treatment can improve the quality of life and prolong the survival of a considerable number of patients.
1.Interventional treatment of hepatocellular carcinoma
Transarterial interventional therapy (TAIT) for primary hepatocellular carcinoma
(1) Principles
①It must be performed in hospitals with digital subtraction angiography machine.
(2) Clinical indications must be strictly mastered.
③The standardization and individualization of treatment must be emphasized.
(2)Applicable groups
①Patients with intermediate and advanced primary liver cancer that cannot be resected by surgery.
②Patients who can be surgically resected but cannot or do not want to undergo surgery due to other reasons (e.g. advanced age, severe cirrhosis, etc.). For the above patients, interventional therapy can be the preferred method among non-surgical treatments. Domestic clinical experience confirms that interventional treatment is most effective for giant hepatocellular carcinoma with relatively intact envelope and large hepatocellular carcinoma. For resectable hepatocellular carcinoma, the factors influencing the preference of surgical resection or interventional treatment include: AFP level; whether the tumor lesion has intact envelope and clear boundary; whether there is cancer thrombus in portal vein.
(3) Postoperative prophylactic treatment for patients with resectable liver cancer.
(3) Contraindications
①Seriously impaired liver function, Child-Pugh grade C;
②Seriously reduced coagulation function, which cannot be corrected;
(3) Portal hypertension with reverse blood flow and complete obstruction of the main portal vein with little formation of collateral vessels (if liver function is basically normal, super-selective catheter technique can be used to embolize the tumor target vessels in stages);
④Infection, such as liver abscess;
⑤ systemic metastasis has occurred extensively, and it is estimated that the treatment cannot prolong the survival of the patient;
(6) Systemic failure;
(7) Cancer occupying 70% or more of the whole liver (if the liver function is basically normal, a small amount of iodine oil can be used for embolization in stages).
(4) Interventional treatment operation specification
①The catheter should be placed in the abdominal trunk or common hepatic artery for imaging, and the image acquisition should include the arterial phase, parenchymal phase and venous phase.
②After careful analysis of the imaging performance and clarification of tumor site, size, number and blood supply artery, super-selective cannulation to the tumor blood supply artery for perfusion chemotherapy.
③Hepatic artery embolization needs to choose the appropriate embolic agent, generally using super-liquefied iodine oil and chemotherapeutic drugs fully mixed into an emulsion. The amount of iodine oil should be flexible according to the size of tumor, blood supply and the number of tumor blood supplying arteries. Super-selective cannulation must be used for embolization.
(5) Follow-up and treatment interval
The follow-up period is usually from 35 days to 3 months after the intervention, in principle, patients should continue to receive TAIT for at least 3 weeks from the time of recovery after the intervention, depending on the survival of the tumor after the treatment, and the efficacy should be determined by the international standard for evaluating the efficacy of solid tumor treatment.
(6) Individualized program based on transarterial intervention (TAIT)
(1) The liver tumor can be partially resected in stage II after shrinking.
②Prophylactic perfusion chemoembolization should be done about 40 days after hepatocellular carcinoma resection.
③TACE alone can be used for portal vein and inferior vena cava cancer embolism if they are asymptomatic, and stenting and radiation therapy can be used if obstruction symptoms occur.
④TACE-based individualized program also involves the treatment of ruptured liver tumor bleeding, TACE combined with ablation, etc.
2.Ablation therapy of liver cancer
Ablation therapy mainly includes radiofrequency ablation, microwave ablation and anhydrous alcohol injection. The route of ablation can be through skin access, and can also be applied in laparoscopic surgery or open surgery. The main means of image guidance include ultrasound and CT, and the appropriate ablation method can be selected according to the specific conditions of local hospitals.
Indications: tumor volume ≤5cm, tumor number less than 3; patients who are physically unable to tolerate surgery or refuse surgery; patients whose tumors cannot be surgically removed and need palliative treatment, such as large hepatocellular carcinoma or central hepatocellular carcinoma that cannot be surgically removed; patients with severe cirrhosis who cannot tolerate surgery for small hepatocellular carcinoma.