The incidence of primary liver cancer (Hepatocellualr carcinoma, HCC) ranks fifth in the incidence of malignant tumors and second in the mortality rate worldwide, and there are nearly 400,000 new cases of primary liver cancer in China every year, which is closely related to the high prevalence of hepatitis B virus infection in China, as liver cancer starts insidiously, most of the patients are already in advanced stage when they are detected. Therefore, for high-risk groups (hepatitis B or C virus infection, long-term alcohol consumption, smoking, severe fatty liver, family history of tumor, etc.), they should be screened regularly for early detection of tumor, and the examination items should include: tumor markers (AFP, CA19-9, CEA), abdominal ultrasound, liver function and virological index. Wang Dong, Department of Hepatobiliary Surgery, Peking University People’s Hospital
With the progress of treatment concept and diagnostic methods, the proportion of early stage liver cancer detection will gradually increase, and with the rapid development of treatment methods such as surgical resection, liver transplantation, ablation therapy and embolization chemotherapy for liver cancer, the multidisciplinary combined treatment with radical surgery as the core should be emphasized in order to improve the overall prognosis of liver cancer patients and prevent recurrence.
Usually we refer to small hepatocellular carcinoma as hepatocellular carcinoma with diameter ≤ 3 cm, but small hepatocellular carcinoma is not exactly equal to early hepatocellular carcinoma. Early hepatocellular carcinoma refers to single hepatocellular carcinoma or multiple (number ≤ 3) hepatocellular carcinomas with maximum diameter < 3 cm < font=""> and without hepatic vascular invasion and other organ metastases. If small hepatocellular carcinoma is combined with surrounding tiny metastases or vascular invasion, such small hepatocellular carcinoma is not considered as early stage hepatocellular carcinoma and has poor treatment effect. Early stage liver cancer can be treated curatively, and the 5-year survival rate after treatment reaches 50%-70%.
I. Surgical resection and liver transplantation are the exact radical surgery.
Despite the emergence of various new treatment methods, local resection is still the first choice of radical treatment for liver cancer in China. For early-stage hepatocellular carcinoma, local resection should be actively recommended if the patient’s liver function Child-Pugh score is grade A, or although it is grade B, it can be restored to grade A with brief liver-protective treatment, and is not accompanied by serious systemic diseases. With the advancement of hepatobiliary surgery technology, as long as the general condition and liver function of patients permit, the size and part of liver cancer itself no longer constitute a contraindication to surgery. Domestic and international studies have shown that whether radical surgical resection can be performed significantly affects the prognosis of patients with hepatocellular carcinoma.
The status of liver transplantation in liver cancer treatment has been increasing, and the long-term survival rate of patients with early-stage liver cancer after liver transplantation is comparable to that after hepatectomy. For patients with cirrhotic decompensation or with portal hypertension, liver transplantation can simultaneously treat their underlying liver disease and can be the preferred surgical treatment option if conditions permit. During the waiting period for liver transplantation, emphasis should be placed on local control of the tumor and the protection of liver function and the function of various other organs.
Second, ablation has a radical effect in strictly selected cases.
For patients with early-stage hepatocellular carcinoma, ablation therapy is the best alternative to surgery, and radical ablation can be obtained for small hepatocellular carcinoma with a single tumor diameter ≤3 cm. Patients with early-stage hepatocellular carcinoma who do not want to receive surgery and patients with deep hepatocellular carcinoma can be treated by ablation if they do not have serious organ dysfunction such as liver, kidney, heart and brain and normal or near normal coagulation function.
Third, TACE is an important adjuvant treatment for early stage hepatocellular carcinoma.
It is not effective to kill cancer cells only by hepatic artery cannulation embolization and chemotherapy (TACE). Nowadays, TACE is mainly applied to the following three aspects of small liver cancer: 1) prophylactic TACE after early liver cancer surgery; 2) combined with minimally invasive treatment such as ablation; 3) preoperative TACE is feasible for early liver cancer patients with liver transplantation indications to inhibit the growth of cancer cells and delay patients’ waiting time for liver donation. In addition, the effect of TACE is still relatively certain for middle and late stage hepatocellular carcinoma. If the patient’s liver function permits, TACE can delay the progress of HCC to a certain extent.
IV. Improving the differential diagnosis of hepatic occupying lesions that are easily confused with HCC
The main differentiators for HCC include: 1) Regenerative Nodule (RN); 2) Focal Nodular Hyperplasia (FNH); 3) Hepatocellular Adenoma (HCA); 4) Hepatocellular Adenomatous Hyperplasia (HCA). Hyperplasia (Adenomatous Hyperplasia); 5) Macroregenerative Nodules (Macro); 6) Metastases, atypical small hemangiomas, liver abscesses, etc.
During the process of HCC, especially the transformation from regenerative nodules to atypical nodules, neovascularization of tumor appears, which combined with various imaging means can show or reflect the tumor neovascularization and the change of blood supply associated with it, improve the correct rate of early diagnosis of HCC and reduce the rate of misdiagnosis.
V. Anti-viral therapy is essential.
Clinical and experimental studies have shown that hepatitis B virus and hepatitis C virus infection are not only closely related to the occurrence of hepatocellular carcinoma, but also correlate with postoperative recurrence. Active antiviral therapy can reduce the recurrence rate of hepatocellular carcinoma after surgery while delaying the development of liver fibrosis and protecting liver function.
The overall goal of antiviral therapy for patients with HBV-related HCC is to reduce the recurrence of HCC, reduce HBV reactivation, control disease progression, improve quality of life and prolong survival by suppressing HBV replication to the lowest level through antiviral therapy based on comprehensive treatment for HCC; at the same time, antiviral therapy can improve liver function and reduce the occurrence of end-stage liver disease. At the same time, antiviral therapy can improve liver function, reduce end-stage liver disease events, and create conditions for comprehensive treatment of HCC.
Sixth, it can be supplemented with biological therapy and Chinese medicine.
In recent years, many new adjuvant therapies for liver cancer have emerged, including molecular targeted therapy, immunotherapy, gene therapy, endocrine therapy and other biological therapies, as well as Chinese medicine therapy.
Molecular targeted therapies, represented by sorafenib, have been proven by evidence-based medical research to prolong the survival of liver cancer patients. For immunotherapy, phase I-III liver cancer vaccine clinical trials are currently underway worldwide. For gene therapy, Wonetal introduced AFP reverse splicing target RNA constitutive enzyme into PHC cells via herpes simplex virus to replace RNA residues that efficiently express AFP in hepatocellular liver cancer, resulting in significant retardation of tumor cell growth and reduction of AFP-expressing RNA levels in the cells.
These therapies should theoretically further improve prognosis after radical surgery for early-stage hepatocellular carcinoma, which remains to be explored by evidence-based medicine.