It is basically a consensus in the domestic academic circles that if liver cancer is detected early, without metastasis, single and small in size, surgical resection is best. However, it has been reported in the literature that a single lesion detected by preoperative ultrasound, CT or MRI, postoperatively or intraoperatively proves that about 30% of patients have already had vascular invasion or intrahepatic metastasis; there is also the higher recurrence rate of hepatocellular carcinoma after surgery, and the development of minimally invasive interventional techniques in recent years, etc., which are increasingly evidence to challenge the authority of surgery in this field. A large Japanese case study reported that interventional embolization chemotherapy combined with radiofrequency ablation for small hepatocellular carcinoma had a 5-year survival rate comparable to surgery.
Based on the above points, for patients with early stage small hepatocellular carcinoma, we should carefully analyze and carefully perform preoperative examination, and patients with many comorbidities and high potential risk for surgery do not necessarily have to undergo surgery. Besides surgery, what other methods are available?
1.Hepatic artery chemoembolization
Clinical randomized controlled studies and Meta-analysis have confirmed that hepatic artery embolization chemotherapy can significantly prolong the 3-year survival rate of patients. For small hepatocellular carcinoma less than 5 cm, hepatic segmental or subhepatic embolization can achieve similar effect as surgical resection if complete embolization can be achieved.
Hepatic artery embolization chemotherapy is mainly used for hepatocellular carcinoma that cannot be resected surgically and whose liver function is in a compensated state. For patients with hepatocellular carcinoma with decompensated liver function (e.g. Child C grade), there is no evidence to show that it can prolong the survival of patients.
2.Intra-tumoral anhydrous alcohol injection
More than 20 years of clinical practice has proved that the selective application of intratumoral anhydrous alcohol injection in the treatment of hepatocellular carcinoma has a long-term effect similar to that of surgical resection. For hepatocellular carcinoma less than 5 cm in diameter with compensated liver function, the 3-year and 5-year survival rates reach 64% and 41%, similar to that of survival after surgical resection.
To ensure complete tumor destruction, PEI often requires multiple injections. The effect of PEI can be improved if it is properly combined with TACE. The ischemic necrosis caused by TACE destroys the fibrous septum inside the tumor, which is conducive to the diffusion of anhydrous alcohol and reduces the residual tumor after treatment.
3.Radiofrequency ablation
Radiofrequency ablation is a widely used local treatment for liver cancer in recent years. It has become the main treatment method for small hepatocellular carcinoma other than surgical resection because of its precise efficacy and small damage to liver function. Radiofrequency destruction treatment can be performed percutaneously under imaging guidance, or laparoscopically or openly.
For small hepatocellular carcinoma smaller than 5 cm, randomized controlled studies have shown similar long-term clinical outcomes to surgical resection. With the widespread availability of radiofrequency ablation, the maximum extent of single-needle destruction has been extended to 7 cm, and there is increasing evidence that radiofrequency destruction therapy can be an alternative to surgical resection.
In a comparative study with anhydrous alcohol ablation, radiofrequency ablation showed a more definite efficacy.
4.Microwave coagulation therapy
Use the thermal effect of microwave to cause coagulative necrosis of the tumor. Domestic Dong Baowei et al. reported that the 5-year survival rate of MCT could reach 56.7%. Compared with RFA, the effect of the two is similar. For example, in a randomized controlled study, 96% of lesions were completely necrotic after RFA treatment, and 89% were completely necrotic after MCT treatment.
5.Molecular targeted therapy
As an important advance in the treatment of liver cancer in 2007, the results of a multicenter, randomized controlled study of sorafenib for advanced hepatocellular carcinoma (SHARP) showed that sorafenib significantly prolonged the overall survival of patients with advanced disease (median survival of 10.7 months for sorafenib versus 7.9 months for control placebo). However, the expensive price of sorafenib limits its use. Thalidomide (Response Stop) is preferred as a drug with similar effect and cheaper price. We applied thalidomide combined with interventional treatment for primary liver cancer, which can significantly prolong the survival of patients with liver cancer compared with interventional treatment alone.
6. Relay cellular immunotherapy
As the development of traditional surgery, radiotherapy and chemotherapy still cannot cure tumors, people are casting more and more eyes on biological immunotherapy of tumors. In 1985, the National Cancer Institute established immunotherapy for cancer as the fourth therapy after surgery, radiotherapy and chemotherapy. Relay immunity is one of the biological therapies for tumors. What does it mean? Relay immunity is the infusion of sensitized lymphocytes (with specific immunity) or products of sensitized lymphocytes (e.g. transfer factors and immune ribonucleic acid, etc.) to a person with low cellular immunity (e.g. tumor patient) so that he or she can acquire anti-tumor immunity. Successive immunity or inherited immunity, which is like gaining financial power by inheriting someone else’s property, is a type of immunotherapy used to treat tumors. This therapy has been developed from NK cell, LAK cell, CTL cell, TIL cell therapy in the past to DC and CIK cell therapy. This method is the most promising method in addition to surgery and interventional treatment methods.
7.Systemic chemotherapy
Systemic chemotherapy is the traditional treatment method for liver cancer. However, due to the insensitivity of liver cancer to chemotherapy, there is no definite evidence so far that liver cancer patients can benefit from systemic chemotherapy in terms of survival.