Brief background.
Surgical treatment of hepatocellular liver cancer has been carried out in China as early as the mid-1950s. In the last half century, through the joint efforts of several generations, the surgical treatment of hepatocellular liver cancer has developed greatly and achieved better results. By the 1990s, the technique of liver surgery has matured and there is no longer any forbidden area of liver surgery, nor is it considered that giant liver cancer cannot be removed. At present, it is the unanimous opinion at home and abroad that surgical resection is still the first choice and the most effective measure to treat this disease.
Meanwhile, due to the rapid development of modern science and technology, some new therapeutic techniques have emerged one after another since the 1980s and have been applied clinically with certain effects. These techniques include: radio-interventional therapy, radiofrequency therapy, X-blade therapy, cryotherapy, microwave therapy and anhydrous ethanol (alcohol) intratumoral injection therapy. Clinical observation shows that these techniques are still inappropriate in the selection of indications for the treatment of hepatocellular liver cancer, which makes some patients miss the opportunity of reasonable surgical treatment or even cure, resulting in irreversible consequences. At that time, there was no uniform reference standard in China on how to choose reasonable treatment measures for patients with hepatocellular liver cancer. Many doctors suggested to us that a national reference plan with authority should be formulated. In this regard, with the support and guidance of academicians Qiu Fazu, Wu Mengchao, Tang Zhaoyou and Huang Zhiqiang, the organizing committee of the 6th National Conference on Liver Surgery drafted a draft on “Selection of Surgical Treatment for Primary Liver Cancer”, which was revised by 12 famous liver surgeons in China and presented at the 6th National Conference on Liver Surgery held in Wuhan from October 25 to 28, 2000. The draft of “Surgical Treatment Options for Primary Liver Cancer” was revised by 12 famous liver surgeons in China, and was adopted by the experts of the Hepatology Group of the Chinese Society of Surgery after discussion during the 6th National Liver Surgery Conference held in Wuhan on October 25-28, 2000. After the announcement of this option, it provided a reference basis for the surgical community in China to choose the treatment method for hepatocellular liver cancer and was widely praised. However, with the continuous updating of certain concepts and technical improvements in hepatocellular carcinoma surgery, certain contents of the original selection scheme needed to be amended accordingly. Thus, the original selection scheme was revised for the first time in 2004 after discussion by the Hepatology Group of the Chinese Society of Surgery. However, with the application of the revised protocol in China, people’s understanding of the surgical treatment of hepatocellular carcinoma has further deepened, and some new opinions have been put forward, such as “primary hepatocellular carcinoma”, which is the usual international name for “hepatocellular hepatocellular carcinoma”; the size classification of tumor, there are several In 2007, we sent the relevant opinions to the experts of this group for discussion, and at the end of September 2008, we summarized the opinions of the experts and determined the contents of the second revision of this program. The revised protocol is now published as follows.
1. Classification of hepatocellular liver cancer according to size: micro hepatocellular carcinoma, the maximum diameter of tumor ≤ 2.0cm
Small hepatocellular carcinoma, the maximum diameter of tumor >2.0cm, ≤5.0cm
Large hepatocellular carcinoma, the maximum diameter of tumor >5.0cm, ≤10cm
Large hepatocellular carcinoma, the maximum diameter of tumor >10cm
2.Surgical treatment methods for hepatocellular liver cancer
2.1 Liver resection.
① Partial hepatectomy
i. According to the surgical approach, it is divided into: open hepatectomy and transluminal hepatectomy.
ii. According to the surgical approach: anatomical hepatectomy and non-anatomical hepatectomy.
iii. According to the completeness of tumor resection, it is divided into: radical hepatectomy and non-radical hepatectomy.
Total liver resection in situ liver transplantation
i. In situ total liver transplantation.
ii. In situ partial liver transplantation.
2.2 Other surgical treatment methods.
① intraoperative hepatic artery ligation or hepatic artery embolization chemotherapy.
②hepatic artery cannulation chemotherapy.
iii. portal vein cannulation chemotherapy.
④ intraoperative cryotherapy or argon helium knife treatment.
⑤ Intraoperative radiofrequency or microwave therapy.
3.Criteria for radical liver resection for hepatocellular carcinoma
3.1 Medium judgment criteria.
① the hepatic vein, portal vein, bile duct and inferior vena cava are not invaded by the tumor.
②No invasion of adjacent organs, no hilar lymph nodes or distant metastasis.
③ complete resection of the tumor within the hepatic segment, lobe or half of the liver according to the intrahepatic anatomical demarcation.
④The cut edge of the liver is ≥1cm from the tumor border; if the cut edge is <1cm, but no tumor cells remain in the histological examination of the liver section on the side of the residual liver, that is, the cut edge is negative.
3.2 Postoperative judgment criteria.
①No tumorigenic lesions were found within 2 months after surgery by ultrasound, CT and other imaging examinations.
②If AFP is elevated before surgery, the level of AFP is within the normal range when measured quantitatively two months after surgery.
4. Surgical indications for hepatic resection of hepatocellular liver cancer
4.1 General condition of the patient.
①Patients with good general condition and no obvious organic lesions of important organs such as heart, lung, kidney and brain.
② normal liver function, or only mild damage, according to liver function grading is A grade; or liver function grading is B grade, after short-term liver protection treatment liver function recovery to A grade (Child-Pugh liver function grading see Table 1).
(iii) Liver reserve function (e.g. ICGR15) is basically within the normal range.
④No unresectable extrahepatic metastatic tumors.
4.2 Local lesion status.
Radical hepatic resection is feasible for the following cases that meet items 1-4 in 4.1 above
①single hepatocellular carcinoma with smooth surface, clear boundary or pseudo-envelope formation, and <30% of liver tissue destroyed by tumor (measured by CT or MRI if necessary); or although the liver tissue destroyed by tumor is >30%, the tumor-free side of the liver has obvious compensatory enlargement, reaching more than 50% of the whole liver tissue.
② multiple tumors with less than 3 tumor nodules confined to a segment or a lobe of the liver.
Only non-radical hepatectomy is feasible in the following cases that meet items 1 to 4 in 4.1 above:
(1) 3 to 5 multiple tumors beyond half of the liver, with multiple limited resections; or tumors confined to 2 to 3 adjacent liver segments or half of the liver, with imaging showing significant compensatory enlargement of the tumor-free liver tissue to more than 50% of the whole liver.
(2) Hepatocellular carcinoma located in the central region of the liver (middle lobe of the liver, i.e. section IV, V, VIII), with significant compensatory enlargement of tumor-free liver tissue, reaching more than 50% of the whole liver.
③For those with lymph node metastasis in the hilar region, if the primary liver tumor can be resected, the tumor should be removed and lymph node dissection in the hilar region should be performed at the same time; for those who have difficulty in lymph node dissection, radiofrequency, microwave, freezing or injection of anhydrous ethanol can be performed intraoperatively, or radiotherapy can be performed after surgery.
If the primary liver tumor is resectable, it should be removed together with the invaded organ. For single metastatic tumor of distant organs (such as single lung metastasis), resection of the primary liver cancer and metastases can be performed simultaneously.
5. Selection of surgical treatment for recurrent hepatocellular liver cancer
5.1 For recurrent hepatocellular carcinoma within 1 year after the last surgery, in principle, re-operation for resection is not considered and other surgical methods can be used.
5.2 For recurrence after 1 year from the last surgery, the principles of surgical treatment are the same as when the liver cancer was first detected.
6. Indications for resection of unresectable hepatocellular carcinoma with reduced grading
For unresectable hepatocellular carcinoma, the combination of non-surgical treatment modalities (including transhepatic artery embolization chemotherapy, portal vein embolization chemotherapy, internal and external radiation therapy, systemic immunochemotherapy, etc.) may effectively reduce its grade, thus making some patients’ hepatocellular carcinoma resectable. The indications for liver resection are the same as 4.
7. Indications for surgery for hepatocellular carcinoma combined with portal vein tamponade/ or vena cava tamponade/ or right atrial tamponade
7.1 General condition of the patient.
Requirements are the same as for hepatectomy.
7.2 Local conditions.
① Tumor resectable as judged by the criteria of indications for hepatic resection for hepatocellular carcinoma.
② cancer tethering filling the main branch or (and) trunk of the portal vein and further development will soon endanger the patient’s life.
③ It is estimated that the time of cancer tumor formation is relatively short and mechanization has not yet occurred.
The above cases are suitable for portal vein trunk dissection to remove the cancer tamponade and non-radical hepatectomy at the same time.
If the cancer thrombus is located in a small portal vein branch above the liver segment, it can be removed together with the portal vein branch at the same time of resection.
If the tumor is found to be unresectable, intraoperative chemotherapy with selective hepatic artery cannulation or portal vein cannulation, radiofrequency, microwave or cryotherapy can be performed after portal vein trunk dissection to remove the embolus.
In case of combined vena cava embolism, the vena cava can be cut to remove the embolism under the blockage of whole liver blood flow, and the liver tumor can be removed at the same time.
When combined with right atrium cancer embolus, the right atrium can be removed by open-heart incision and liver tumor can be removed at the same time.
8.Surgical indications of hepatocellular liver cancer combined with bile duct cancer embolism
8.1 General condition of the patient.
The basic requirements are the same as hepatectomy. It should be noted that this patient has obstructive jaundice, so the liver function classification cannot be fully judged according to Table 1, and emphasis should be placed on the patient’s general condition, A/G ratio and prothrombin time, etc.
8.2 Local conditions.
(i) The tumor is resectable as judged by the criteria of indications for liver resection for hepatocellular liver cancer.
② the cancer thrombus is located in the left hepatic duct or right hepatic duct, common hepatic duct and common bile duct.
③The cancer thrombus was estimated to have formed for a short period of time and had not yet undergone mechanization.
④The cancer thrombus has not invaded the bile duct branches above grade 2 on the healthy side.
The above cases are suitable for choledochotomy to remove the cancer embolus and non-radical hepatectomy at the same time.
If the cancer embolus is located in a small branch of the hepatic duct above the hepatic segment, it can be removed together with the hepatic tumor at the same time.
If the tumor is found to be unresectable, intraoperative selective hepatic artery cannulation and embolization chemotherapy, radiofrequency, microwave or cryotherapy can be performed after resection of the common bile duct to remove the embolus.
9. Selection of cases for B-ultrasound or CT-guided percutaneous local treatment (radiofrequency, freezing and microwave)
9.1 General condition of the patient.
①Patients in good general condition, no obvious organomegaly of heart, lung, kidney, brain and other important organs, good functional status, or only mild damage.
② normal liver function, or only mild damage, according to the liver function classification is A or B grade.
9.2 Local conditions.
①Single tumor, or cancer foci <5, single tumor diameter <5cm, accompanied by severe cirrhosis and significant reduction in whole liver volume.
②Recurrent hepatocellular carcinoma recently recurred after hepatectomy, which is not suitable or the patient is unwilling to accept another hepatectomy.
Indications for intraoperative application: ① local treatment of residual liver section if cancer cells are suspected to remain in the tumor cut edge; ② local treatment of intrahepatic residual foci found by intraoperative ultrasound examination after resection of the main lesion; ③ intraoperative application of local treatment after hepatic artery cannulation embolization chemotherapy for unresectable massive liver cancer. ④Treatment of bleeding from liver trauma during hepatectomy.
10.Case selection of anhydrous ethanol (alcohol) intratumoral injection
10.1 General condition of the patient.
①The patient’s general condition is good, without obvious organic lesions of important organs such as heart, lung, kidney and brain; or organic lesions of important organs such as heart, lung, kidney and brain, with poor functional status.
② significant impairment of liver function, not suitable for hepatectomy.
8.2 Local conditions.
①Single tumor, or multiple nodular tumors, but no more than 5 cancer foci.
②hepatocellular carcinoma that has recently recurred after hepatectomy and is not suitable or the patient is unwilling to undergo another hepatectomy.
11. Indications for surgery for hepatocellular liver cancer combined with cirrhotic portal hypertension
11.1 General condition of the patient.
①Patients in good general condition, without obvious organic lesions of important organs such as heart, lung, kidney and brain.
② normal liver function, or only mild damage, according to liver function grading is A grade, or liver function grading is B grade, and liver function is restored to A grade after short-term liver protection treatment.
③ normal range of liver reserve function (e.g. ICGR15).
④No unresectable extrahepatic metastatic tumor.
11.2 Local conditions.
11.2.1 Resectable hepatocellular carcinoma
① those with obvious splenomegaly and hypersplenism (WBC <3×109/L, platelets <50×109/L) manifestations, splenectomy can be performed at the same time.
② Those with obvious esophageal and fundic varices, especially those who have experienced hemorrhage from ruptured esophagogastric varices, can be considered for simultaneous peripancreatic vascular dissection; those with severe gastric mucosal lesions, if the patient’s intraoperative condition allows, splenorenal shunt or other types of selective portal shunt should be performed.
11.2.2 Hepatocellular carcinoma found to be unresectable intraoperatively
①Patients with obvious splenomegaly and hypersplenism (WBC＜3×109/L, platelets＜50×109/L), without obvious esophagogastric fundic varices, should undergo intraoperative selective hepatic artery cannulation embolization chemotherapy, radiofrequency, microwave or cryotherapy while splenectomy is performed;
(2) If there is obvious esophagogastric fundic varices, especially if there is a large bleeding of ruptured esophagogastric fundic varices.
If there is obvious esophagogastric varices, especially if there has been a large bleeding of ruptured esophagogastric varices and there is no serious gastric mucosal lesion, splenectomy or splenic artery ligation with coronary vein suture is feasible; whether to perform dissection is decided according to what the patient sees intraoperatively. Hepatocellular carcinoma can be treated intraoperatively with radiofrequency, microwave or cryotherapy, but not with hepatic artery cannulation and embolization chemotherapy.
12.Application of laparoscopic technology in the surgical treatment of hepatocellular carcinoma
In recent years, laparoscopic technology in liver surgery has developed rapidly, and some units have carried out hepatic resection of hepatocellular carcinoma via laparoscopy one after another. In order to meet the development and demand of laparoscopic technology in the surgical treatment of liver cancer, we propose the following selection criteria for reference.
12.1 Indications for local treatment of hepatocellular carcinoma via laparoscopy
①Tumor is located on the top of hepatic diaphragm, which is affected by gas in the lung, and there is difficulty in B-ultrasound guidance, and there is a risk of damage to diaphragm or pericardium in percutaneous local treatment.
②Tumor is located on the liver surface, and there is a risk of damaging adjacent organs (such as gallbladder, stomach, colon, etc.) during percutaneous local treatment.
③The requirements for the general condition of the patient are the same as those for local treatment by percutaneous puncture.
12.2 Indications for hepatic resection of hepatocellular carcinoma via laparoscopy
①hepatocellular carcinoma located in the left half of the liver, or V or VI segment of the right half of the liver.
②the maximum diameter of the tumor is less than 6 cm; for tumors located at the marginal part of the liver surface, the tumor diameter can be relaxed to 10 cm.
③If technical conditions allow, right hemicolectomy can also be performed laparoscopically.
④The requirements for general condition of patients are the same as those for open hepatectomy.
13.Indications for liver transplantation for hepatocellular liver cancer
At present, there is no uniform standard in China. According to the local condition of the tumor, we recommend to adopt the international widely used Milan standard or UCSF standard.
13.1 General condition of patients
①Patients are in good general condition, no significant organic lesions of heart, lung, kidney and brain;
② Significant impairment of liver function, Child-Pugh liver function classification grade C or long-term grade B.
③No extrahepatic metastatic tumors.
13.2 Italian Milan criteria
①Single tumor diameter <5cm, or number of tumors <3, maximum diameter <3cm.
②No invasion of blood vessels and lymph nodes.
13.3 University of California, San Francisco (UCSF) criteria
①Single tumor diameter <6.5cm, or number of tumors <3, maximum diameter <4.5cm, total tumor diameter <8cm.
②No associated vascular and lymph node invasion.