Primary liver cancer (PLC) is one of the most common malignant tumors in clinical practice, with a global incidence of over 626,000/year, ranking 5th among malignant tumors, and nearly 600,000/year, ranking 3rd among tumor-related deaths. It ranks second after lung cancer in tumor-related deaths. Therefore, liver cancer is a serious threat to the health and life of our people.
Since the majority of PLC is hepatocellular carcinoma (HCC), the clinical management involves many disciplines such as medical, surgical, interventional, radiotherapy, Chinese medicine and medical imaging, therefore, the standardized diagnosis and treatment of hepatocellular carcinoma needs to be discussed and formulated by multidisciplinary experts in order to select the most suitable preferred treatment and comprehensive therapeutic measures for patients after diagnosis. Currently, there are international guidelines for the treatment of liver cancer that can be used for reference, mainly including.
① Clinical practice guidelines for liver cancer from the National Comprehensive Cancer Network (NCCN).
②The American Association for the Study of Liver Diseases (AASLD) clinical treatment guidelines for HCC.
③The British Society of Gastroenterology (BSG) treatment guidelines.
④ Consensus developed by the American College of Surgeons (ACS); covering the staging, surveillance, screening, diagnosis and treatment of hepatocellular carcinoma.
Staging of hepatocellular carcinoma
For the staging of HCC, there is no uniformity in the AASLD, ACS and NCCN guidelines, and the emphasis varies. Among them, the TNM staging approach adopted by the NCCN is the most standardized internationally, but is less recognized because of.
(i) vascular invasion, which is crucial to the treatment and prognosis of HCC, is difficult to determine accurately before treatment (especially before surgery).
(ii) Treatment of HCC places great emphasis on liver function compensation, while TNM staging does not indicate the patient’s liver function status.
③ The variability of TNM staging among versions makes it difficult to compare and evaluate. AASLD adopts the Barcelona Liver Cancer Center (BCLC) staging and treatment strategy, which takes into account tumor, liver function and systemic conditions in a more comprehensive manner and is supported by high-level evidence of evidence-based medicine, and is now more recognized and widely adopted worldwide.
Surveillance and screening for hepatocellular carcinoma
The four international guidelines mentioned above all place great emphasis on early screening and early surveillance of HCC and are all based on evidence-based medical evidence and have a high degree of credibility. The views on screening indicators are relatively consistent and include two main ones, serum alpha-fetoprotein (AFP) and liver ultrasonography. For men ≥ 35 years of age with HBV and/or HCV infection and a high risk of alcoholism, screening is generally performed at 6-month intervals. For AFP > 400 μg/L without liver occupancy on ultrasound, care should be taken to exclude pregnancy, active liver disease, and tumors of embryonic origin in the gonads; if this can be ruled out, CT and/or MRI should be performed. If AFP is elevated but not at the diagnostic level, in addition to the above-mentioned conditions that may cause increased AFP should be excluded, the dynamic changes in AFP should be closely tracked, the interval between ultrasound examinations should be shortened to 1~2 months, and CT and/or MRI examinations should be performed when needed. If hepatocellular carcinoma is highly suspected, DSA hepatic artery iodine oil angiography is recommended.
Diagnosis of hepatocellular carcinoma
Diagnostic criteria for HCC include pathological and clinical diagnostic criteria. Diagnostic methods include serum tumor marker (AFP) testing, imaging (including ultrasonography, CT, MRI and DSA angiography) and pathological histological examination (mainly liver tissue biopsy). the BSG guidelines suggest that for patients with cirrhosis, the presence of cirrhosis is first determined, followed by a threshold of 2 cm of occupancy size to start the diagnostic process; while for non-cirrhotic patients AFP level is used to guide the diagnostic process. Internationally, the diagnostic process of AASLD is applied more often, differentiating between the mass and the diagnostic process by occupancy <1 cm, 1 to 2 cm and >2 cm, with emphasis on early diagnosis.
Treatment of hepatocellular carcinoma
The ACS consensus states that the treatment goals for HCC include: cure; local control of the tumor in preparation for transplantation; local control of the tumor and palliative care. Improving quality of life is also an important treatment goal. The NCCN emphasizes the importance of keeping abreast of the times while following evidence-based medicine, and its 2008 edition has introduced the last two years of breakthroughs in the treatment of hepatocellular carcinoma. breakthroughs, namely the inclusion of the molecularly targeted therapy drug sorafenib as one of the standard treatment options for patients with inoperable and advanced HCC.
Diagnosis of primary liver cancer
(i) Early diagnosis
Early diagnosis is crucial. Since the 1970s to 1980s, the early diagnosis of PLC has been greatly facilitated by the gradual popularization and wide application of serum AFP, real-time ultrasound imaging and CT. As the early diagnosis rate has increased significantly, the surgical resection rate has increased and the prognosis has been significantly improved; therefore, the diagnosis of PLC, especially the early diagnosis, is the key to clinical treatment and prognosis.
In terms of early diagnosis, full attention should be paid to the background of liver disease of patients. In China, 95% of PLC patients have a background of hepatitis B virus (HBV) infection, 10% have a background of hepatitis C virus (HCV) infection, and some patients have overlapping HBV and HCV infection. Special attention should be paid to the following risk groups: middle-aged and elderly men with high HBV load, HCV-infected patients, HBV and HCV overlapping infections, alcoholics, co-infected diabetics, and those with a family history of liver cancer. After the age of 35-40, these people should undergo regular screening (including serum AFP test and liver ultrasound) every 6 months; when there is an elevated AFP or “occupying lesion” in the liver area, they should immediately enter the diagnostic process, observe closely and strive to make early diagnosis.
(II) Laboratory diagnosis methods of liver cancer
At present, the qualitative diagnosis of hepatocellular carcinoma in China is still based on the detection of serum AFP, which should be highly regarded.
(1) In China, more than 60% of liver cancer cases have serum AFP > 400μg /L.
(2) There are no other tumor markers with specificity comparable to that of AFP.
(3) AFP detection is less dependent on imaging equipment and new technologies.
(3) Diagnostic imaging methods for hepatocellular carcinoma
In recent years, the progress of medical imaging examination methods is obvious, and the “four definitions” of PLC in clinical practice are as follows