1 Department of General Surgery, The First Clinical Hospital of Harbin Medical University, Harbin, Heilongjiang, China (150001)
Abstract】Hepatocellular carcinoma (HCC) is the fifth most common gastrointestinal tumor worldwide, accounting for more than 90% of primary liver cancer in China. With the advancement of technology and the accumulation of treatment experience, the treatment methods for HCC are constantly being improved. In this paper, we briefly review the most widely used methods and techniques in the field of comprehensive treatment of HCC with relatively good clinical application and compare them with each other in order to enlighten the clinical treatment of primary hepatocellular carcinoma in China. Liu Lianxin, Department of Hepatobiliary Surgery, The First Hospital of Harbin Medical University
Hepatocellular carcinoma (HCC) is the fifth most common gastrointestinal malignancy in the world, accounting for more than 90% of primary liver cancer in China, and about 110,000 people die of HCC each year [1]. 548,600 people died of HCC worldwide in 2000, and the trend is increasing [2]. The early symptoms of HCC are atypical and difficult to detect clinically. In fact, most of the early detection of HCC is unintentional on physical examination or after deeper investigation of atypical symptoms, and patients are rarely seen on their own initiative [3]. The treatment of late stage HCC is scarce and ineffective. The choice of treatment for HCC depends on the location of the tumor, the extent of the lesion, whether it is metastatic or not, and liver function. Surgery is the only possible cure for HCC, including partial hepatectomy and orthotopic liver transplantation (OLT). Systemic or local palliative approaches are often used for patients who cannot tolerate surgery due to poor liver function or inoperable due to multiple tumors, or to control tumor growth while awaiting liver transplantation. Palliative means include Chinese medicine and diet therapy; local treatment such as hepatic artery embolization, percutaneous ethanol injection (PEI), radio frequency ablation (RA) and cryosurgery; radiotherapy including endogenous and exogenous; systemic treatment such as antagonistic hormone therapy and biological therapy. Systemic treatments such as antagonistic hormone therapy and biologic therapy.
1 Surgical treatment
1.1 Partial hepatectomy has shown that the efficacy of partial hepatectomy for resectable HCC is positive, aiming at complete resection of the tumor and some surrounding normal tissues and ensuring regeneration of the remaining liver and maintaining physiological needs. In the United States, Jarnagin et al [4] studied 1,083 patients with partial hepatectomy.
Jarnagin et al [4] analyzed the 10-year follow-up results of 1,083 patients with partial hepatectomy, suggesting that the 5-year survival rate of patients with hepatectomy for HCC was more than 30%; multicenter data suggest that the 5-year survival rate after surgery can be 30%-50% overall, and 40%-60% for small HCC [5]. The postoperative survival statistics of 6,446 HCC cases in the Eastern Hepatobiliary Hospital showed a 5
The 5-year survival rate was 53.2% for HCC and 79.8% for small HCC [6]. Partial hepatectomy with strict indications and improved techniques has become a safe and effective method for HCC treatment. In China, more than 80% of HCC patients are combined with cirrhosis or chronic hepatitis, and in recent years, the choice of surgical procedure is gradually transitioning from regular hepatectomy to irregular or partial radical resection, with a significant decrease in complications and morbidity and mortality. The main factors limiting surgical resection are tumor size, location, number, and whether the tumor invades blood vessels.56 The indications for partial hepatectomy include Child-Pugh grade A, the presence of pseudoenvelope, 5 cm in diameter or both left and right lobes, and in principle, timely surgery. Lai et al [7] used an anterior approach to hepatectomy, in which the parenchyma of the liver was incised in front of the inferior vena cava when the liver could not be freed, and the right hemicolectomy was completed by separating the surrounding ligament. In combination with the anterior approach, the right hepatic hemicolectomy can be completed without freeing the liver. This method can shorten the hepatic resection path and greatly improve the safety of anterior approach hepatectomy, and also broaden the indications for anterior approach hepatectomy [9], which is promising and valuable. At present, less than 1/3 of patients with HCC have the opportunity to undergo surgery, and the main reasons for inoperability are severe cirrhosis, scattered tumor distribution, and extrahepatic metastases. However, in recent years, the overall HCC resection rate has increased significantly and the surgical mortality rate has decreased significantly. According to the data from the Institute of Liver Cancer of Zhongshan Hospital, the surgical resection rate was 20.3% (24/118) from 1958 to 1967, 27.5% (98/356) from 1968 to 1977, 9.9% (285/715) from 1978 to 1987, and 71.5% (1457/2038) from 1988 to 1997. The indications for surgical resection of HCC have also been expanded compared to the previous ones, and Zhou et al [11 1.2 OLT is theoretically the best choice for the treatment of HCC, as it not only restores liver function, but also ensures the removal of all tumor cells and precancerous environment in the sclerotic liver. The efficacy of OLT in early-stage HCC patients is not good, and the survival rates of OLT versus partial hepatectomy for HCC
The ratios of 1-, 3-, and 5-year survival rates are 40%:82%, 36%:71%, and 26%:45%, respectively [12]; the 5-year survival rate of OLT has been reported to be 20% to 30%, with better outcomes seen in patients with fibrous laminar HCC, microscopic HCC, and small cancerous foci found after total liver resection (incidentaloma) [13]. The selection of indications for OLT in the United States is based on the California and Pittsburgh criteria: single tumor diameter