Due to the rapid development of modern science and technology, some new therapeutic techniques have appeared one after another and have been continuously promoted and applied in clinical practice, so that the surgical treatment of primary liver cancer has achieved certain effects. These techniques include: radio-interventional therapy, radiofrequency therapy, X-blade therapy, cryotherapy, microwave therapy, anhydrous ethanol (alcohol) intratumoral injection therapy, etc. There is no uniform reference standard in China on how to choose reasonable treatment measures for primary liver cancer patients. The draft of “Selection of Surgical Treatment for Primary Liver Cancer” was drafted by the Preparatory Committee of the 6th National Conference on Liver Surgery and discussed and approved by the experts of the Liver Surgery Group of the Chinese Society for Surgery. The full text of the selection plan is published below as a reference basis for the surgical community in China to choose the treatment method for primary liver cancer in the future.
Surgical indications for liver resection of primary liver cancer
I. General condition of patients
1. The general condition of the patient is good, and there are no obvious organic lesions of important organs such as heart, lung and kidney.
2.The liver function is normal or only mildly damaged, and the liver function is graded as grade I; or the liver function is graded as grade 2, and after short-term liver care treatment, there is significant improvement and the liver function is restored to grade I.
3.Liver reserve function (such as ICG,R15) is in normal range.
4.No extensive extrahepatic metastatic hepatocellular carcinoma tumor.
II. Local lesion condition
(a) Radical hepatectomy can be performed in the following cases
1.Single microscopic hepatocellular carcinoma (diameter ≤2cm).
2.Single small hepatocellular carcinoma (diameter >2cm, ≤5cm).
3.Single large hepatocellular carcinoma (diameter >5cm, ≤10cm) or giant hepatocellular carcinoma (diameter >10cm.) with smooth surface, clear surrounding boundary and less than 30% of liver tissue destroyed by the cancer foci.
4.Multiple hepatocellular carcinomas with less than 3 nodes and confined to a section or a lobe of the liver.
(B) Only palliative hepatectomy is feasible in the following cases.
1.3-5 multiple tumors beyond half of the liver for multiple limited resection; or hepatocellular carcinoma confined to 2-3 adjacent liver segments or half of the liver, and imaging shows that the liver tissue on the tumor-free side has obvious compensatory enlargement, reaching more than 50% of the whole liver.
2.Large hepatocellular carcinoma or giant hepatocellular carcinoma in the left or right half of the liver with clearer boundary and the first and second hepatic hilum uninvaded; imaging shows that the tumor-free side of the liver has obvious compensatory enlargement of more than 50% of the whole liver tissue.
3.Large hepatocellular carcinoma located in the central region of the liver (middle lobe of the liver, or segment IV, V or VIII), with obvious compensatory enlargement of the tumor-free liver tissue, reaching more than 50% of the whole liver.
4.Large hepatocellular carcinoma or giant hepatocellular carcinoma in segment Ⅰ or Ⅷ.
5.For those with lymph node metastasis in the hilar region, if the primary hepatocellular carcinoma can be resected, tumor should be resected and lymph node dissection in the hilar region should be performed at the same time; for those who have difficulty in lymph node dissection, radiation therapy can be performed after surgery.
6. If the surrounding organs (colon, stomach, septum or right adrenal gland, etc.) are invaded, if the primary liver tumor can be resected, it should be resected together with the tumor and the invading organs. For single metastatic tumor in distant organs (such as single lung metastasis), resection of primary liver cancer and metastatic cancer can be performed simultaneously.
Indications for surgery of primary hepatocellular carcinoma combined with portal vein thrombosis and/or vena cava thrombosis
I. General condition of patients
The requirements are the same as those for hepatectomy.
Local conditions
1.The tumor is resectable according to the criteria of indications for hepatic resection for primary liver cancer.
2.The cancer embolus fills the main branch or 8 and main trunk of portal vein, and further development will soon endanger the patient’s life.
3.It is estimated that the time of cancer thrombus formation is relatively short and mechanization has not yet occurred. The above cases are suitable for portal vein trunk dissection to remove the cancer embolus and palliative hepatectomy at the same time.
4.If the cancer embolus is located in a small portal vein branch above the liver segment level, it can be removed together with the portal vein branch at the same time of resection.
5.If the tumor is found to be unresectable during the operation, it can be treated by intraoperative selective hepatic artery cannula embolization chemotherapy or portal vein cannula chemotherapy, cryotherapy or radiofrequency treatment after the portal vein trunk is cut to remove the embolus.
6.When combined with vena cava cancer embolism, the vena cava can be incised to remove the cancer embolism under the whole liver blood flow blockage, and the liver cancer can be removed.
Surgical indications of primary liver cancer combined with bile duct cancer embolism
I. General condition of patients
The basic requirements are the same as hepatectomy. It should be noted that such patients have obstructive jaundice, and the liver function classification should be judged with emphasis on the patient’s general condition, A/G ratio and prothrombin time, etc.
II. Local conditions
1.The tumor is resectable as judged by the criteria of indications for liver resection for primary liver cancer.
2.The cancer thrombus is located in the left hepatic duct or right hepatic duct, common hepatic duct and common bile duct.
3.It is estimated that the time of cancer thrombus formation is relatively short and mechanization has not yet occurred.
4.The 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 palliative hepatectomy at the same time.
5.If the cancer embolus is located in a small branch of hepatic duct above the level of liver segment, it can be resected together with the branch of hepatic duct at the same time without removing the embolus through choledochotomy.
6.If the cancer foci are found to be unresectable, intraoperative selective hepatic artery cannulation embolization chemotherapy, freezing or radiofrequency treatment can be performed after the resection of common bile duct to remove the cancer embolus.
Case selection of radiofrequency, freezing and microwave treatment techniques
I. General condition of patients
1.The general condition of the patient is good, no obvious organic lesions of heart, lung, kidney and other important organs, and good functional status, or only mild damage.
2.The liver function is normal, or only mildly damaged, according to the liver function classification is grade 1 or grade 2.
Local conditions
1.Single cancer foci or less than 5 cancer foci; tumor diameter less than 5 cm.
2.Recurrent hepatocellular carcinoma after hepatectomy, which is not suitable or the patient is unwilling to undergo another hepatectomy.
These techniques can be performed by percutaneous liver puncture under ultrasound guidance or applied during surgery; using these techniques for liver trauma treatment during hepatectomy can not only destroy the residual cancer cells at the trauma, but also help to stop bleeding at the trauma, which increases the safety of surgery.
Case selection of anhydrous ethanol (alcohol) intratumoral injection for cancer foci
I. General condition of patients
1.The general condition of the patient is good, without obvious organic lesions of important organs such as heart, lung and kidney; or organic lesions of organs such as heart, lung and kidney, with bad functional status.
2.Hepatic function has obvious damage, and hepatectomy is not suitable.
II. Local conditions
1.Single tumor, or multiple nodular tumors, but no more than 5 cancer foci.
2.Recurrent hepatocellular carcinoma after hepatectomy, which is not suitable or the patient is not willing to receive another hepatectomy.
Indications for surgery of primary liver cancer combined with cirrhotic portal hypertension
I. General condition of the patient
1.The general condition of the patient is good, and there are no obvious organic lesions of heart, lung, kidney and other important organs.
2.The liver function is normal, or only mildly damaged, and the liver function is graded as grade I; or the liver function is grade II, and after short-term liver care treatment, there is significant improvement, and the liver function is restored to grade I.
3.Liver reserve function (such as ICG,R15) is within normal range.
4.No extra-hepatic metastatic cancer foci.
II. Local situation
1. Resectable hepatocellular carcinoma.
(1) Those with obvious splenomegaly and hypersplenism (wbc less than 3×109/L, platelets less than 50×109/L) can be treated with splenectomy at the same time.
(2) Those who have obvious esophageal and fundic varices, especially those who have experienced hemorrhage from ruptured esophagogastric varices, can be considered for simultaneous peripancreatic vascular dissection; those who have severe gastric mucosal lesions, if the patient’s intraoperative condition allows, splenorenal shunt or other types of selective portal shunt should be performed.
2. Intraoperative hepatocellular carcinoma found to be unresectable.
(1) Those with obvious splenomegaly and hypersplenism (wbc less than 3×109/L, platelets less than 50×109/L) without obvious esophageal and fundic varices should undergo splenectomy with intraoperative selective hepatic artery cannulation embolization chemotherapy, cryotherapy or radiofrequency therapy, etc.
(2) If there are obvious esophageal and fundic varices, especially if there is hemorrhage of esophageal and fundic varices, and there is no serious gastric mucosal lesion, splenectomy or splenic artery ligation with coronary vein suture can be performed; whether to perform dissection is decided according to the intraoperative view. Then, intraoperative radiofrequency or cryotherapy is performed; hepatic artery cannulation embolization chemotherapy is not recommended.
Recommendations for case selection of hepatic artery embolization chemotherapy (HACE) by radio-interventional method
I. General condition of the patient
1, the patient’s general condition is good, no obvious organomegaly of heart, lung, kidney and other important organs, and good functional status.
2.Liver function is normal, or only mildly damaged, according to the liver function classification of grade I or grade II.
Local condition
1.The tumors are multiple and scattered in the left and right halves of the liver.
2.The tumor is large, but the tumor-free side of the liver does not have compensatory enlargement, and the volume is less than 50% of the whole liver.
3.The tumor is small, but there is severe cirrhosis, and the volume of the whole liver is obviously reduced.
4.There is no cancer thrombus in the portal vein of the healthy side of the liver, or there is cancer thrombus, but there is still blood flow through the portal branch.
5.No cancer thrombus in intrahepatic bile duct and extrahepatic bile duct.
6.Recurrent tumor recurrence after hepatectomy for hepatocellular carcinoma, which is not suitable or the patient is not willing to operate again.
In principle, the resectable hepatocellular carcinoma should not be treated with radiological intervention before surgery.
Suggestions for case selection of X-knife treatment technology
I. General condition of patients
1.Patients with good general condition, no obvious organic lesions of heart, lung, kidney and other important organs, and good functional status; or organic lesions of heart, lung, kidney and other important organs, and bad functional status.
2.Hepatic function has more obvious damage, not suitable for hepatectomy.
3.No obvious clinical signs of splenomegaly and hypersplenism (wbc less than 3×109/L, platelets less than 50×109/L).
II. Local conditions
1.Single hepatocellular carcinoma foci with diameter <3cm.
2.Recurrent small cancer foci after hepatectomy, which are not suitable or the patient is unwilling to undergo another hepatectomy.