Primary carcinoma of the liver is one of the common malignant tumors in China, and its mortality rate takes the third place among digestive tract tumors, after gastric cancer and esophageal cancer; among malignant tumors, it is the seventh in men and the ninth in women. There are about 6.35 million new cases of malignant tumors in the world every year, of which liver cancer accounts for 260,000 cases (4% of malignant tumors), of which 42.5% occur in China. Primary liver cancer has a high degree of malignancy, rapid development and poor prognosis. Research shows that the occurrence of liver cancer is mainly related to various viral hepatitis (hepatitis B, hepatitis C, etc.), liver cirrhosis, aflatoxin, alcohol and drinking water pollution, etc. In China, the positive rate of serum hepatitis B markers in primary liver cancer patients is as high as 90%. Therefore, early diagnosis and treatment of high-risk groups of liver cancer (age >40 years, long history of slow hepatitis B, cirrhosis and family history of liver cancer) are of great significance. Zheng Zhaomin, Department of Minimally Invasive Oncology, Shandong Qianfo Mountain Hospital
I. Diagnosis of hepatocellular carcinoma.
1.Serological tests.
Alpha-fetoprotein (AFP): it is one of the most specific methods to diagnose hepatocellular carcinoma, with a positive rate of 60-90%. In the absence of other evidence of hepatocellular carcinoma, hepatocellular carcinoma can be diagnosed if AFP is positive by convective immunoelectrophoresis or quantified >400ng/ml for more than one month, and pregnancy, active liver disease, germinal embryonal tumor can be excluded.
Others: γ-glutamyl transpeptidase, alkaline phosphatase and lactate dehydrogenase, due to the lack of specificity, are mostly used as auxiliary diagnostic indicators.
2.Imaging examination
(1) Ultrasound: It can show the size, shape, location of the tumor and the presence of cancer thrombus in the hepatic vein or portal vein, etc. Its diagnostic rate can reach 84%, and it can detect lesions of 2 cm or smaller in diameter.
(2) Ultrasonography: It can dynamically observe the blood perfusion of intrahepatic occupancies, and has the same efficacy as enhanced CT for the ability to differentiate benign and malignant single small intrahepatic lesions and to judge the local efficacy of liver cancer ablation.
(3) CT: High resolution can detect early hepatocellular carcinoma of about 1 cm in diameter, and the application of enhancement scan can help to differentiate it from hemangioma. It can significantly compensate for the shortcomings of B-ultrasound and gas obscuration.
(4) Angiography (DSA): For carcinoma with rich blood vessels, it can sometimes show occupying lesions with a diameter of 0.5 to 1 cm, and the correct diagnosis rate is up to 90%. It can determine the location, size and distribution of lesions, especially for small hepatocellular carcinoma, which is the best localization diagnosis among various examination methods.
(5) MRI imaging: The diagnostic value is similar to that of CT. It can obtain cross-sectional, coronal and sagittal images, and is better than CT in differentiating benign and malignant hepatic occupying lesions, especially hepatic hemangioma, and can show hepatic veins and portal veins without enhancement.
3.Liver biopsy
Puncture biopsy: Needle aspiration cytology examination by liver aspiration has definite diagnostic significance. At present, fine needle aspiration is mostly performed under B-type ultrasound guidance, which can help improve the positive rate, but there are risks of bleeding, tumor rupture and needle metastasis.
Interventional treatment of hepatocellular carcinoma
(I) Interventional endovascular treatment
1. Indications for hepatic artery embolization chemotherapy (TACE)
(1) Application before resection of liver tumor, which can shrink the tumor and facilitate resection, and at the same time can clarify the number of lesions and control metastasis; (2) middle and late stage hepatocellular carcinoma that cannot be surgically resected, without serious dysfunction of liver and kidney, without complete obstruction of portal vein trunk and tumor occupancy rate <70%; (3) small hepatocellular carcinoma; (4) those who fail in surgery or recur after resection; (5) control of pain, bleeding and arteriovenous fistula; ( 6) prophylactic hepatic artery chemoembolization after hepatectomy for hepatocellular carcinoma. < p="">
2. Contraindications
(1) Severe liver dysfunction, such as: severe jaundice (bilirubin >100μmol/L), hypocoagulability, etc. massive ascites or severe cirrhosis with liver function of child C grade; (2) portal hypertension with reverse blood flow and complete obstruction of the main trunk of the portal vein with little formation of collateral vessels; (3) infection, such as liver abscess, severe peritonitis; (4) cancer accounting for 70% or more of the whole liver (if liver function is basically normal, a small amount of iodine oil can be used for embolization in stages); (5) white blood cells <3,000; (6) (6) those with extensive metastasis; (7) those with systemic failure.
3. Judgment of efficacy
The indicators for judging the efficacy are divided into five categories: clinical cure, apparent improvement, improvement, temporary stability, and progress or deterioration. (1) Clinical cure: tumor lesions disappear or shrink more than 75%, iodine oil deposition in tumor lesions is dense, CT examination shows complete necrosis of tumor tissues, DSA has no tumor blood vessels and tumor staining. A-fetoglobulin is normal. The survival period of the patient is more than 5 years. (2) Significant improvement: the mass shrinks more than 50%, the iodine oil deposit in the tumor foci is dense, the filling area accounts for more than 80% of the mass area. The methemoglobin decreased to less than 70% of the preoperative level, and the patient survived for more than 1 year. (3) Improvement: Mass shrinkage >25%; but <50%, non-uniform deposition of iodine oil in the tumor foci, filling area <50% of the mass area; CT examination shows that the tumor tissue is partially alive, partially necrotic, and the necrotic area accounts for about 30%-50%;. Methemoglobin decreased to less than 50% of the preoperative level, and the patient survived for more than 6 months. (4) Progression or deterioration: enlargement of the mass, no iodine oil deposition in the tumor foci or scattered spots, filling area <50% of the mass area. ct examination shows that most of the tumor tissues are alive, tumor blood vessels are obviously increased, tumor staining is obvious, new tumor lesions are visible. Elevated alpha-fetoprotein.
(II) Extravascular interventional therapy
1.Microwave/radiofrequency, anhydrous alcohol ablation indications
(1) Liver cancer with single tumor ≤6.5cm. or 2-3 tumors with the largest lesion <6cm.
(2)Poorly located liver tumor or located in two lobes or invading large blood vessels, which is not suitable for surgical resection. (3) Multiple metastatic carcinomas in the liver with less than 5 tumors and maximum tumor diameter <3-4cm; single metastatic carcinoma in the liver treated before surgical resection of the primary cancer.
(4) Patients who cannot tolerate systemic chemotherapy and other local treatments, and whose radiotherapy effect is not significant. (5) Microscopic hepatocellular carcinoma ≤2cm, precancerous lesions.
(6) Those who recur after liver tumor resection.
2. Contraindications
(1) Diffuse hepatocellular carcinoma combined with cancer embolism.
(2) Severe systemic failure or decreased resistance (white blood cell <3×109/L).
(3)Those with active infection.
(4) Uncorrected period of coagulation dysfunction (platelets <50×109/L, prolonged bleeding and clotting time).
(5) Patients equipped with cardiac pacemakers and patients with severe large aneurysms should be cautious and should be supervised by a specialist if necessary.
3.Pre-operative preparation
(1) Physical examination of the patient, medical history, cardiovascular and cerebrovascular diseases and diabetes mellitus should be understood and medication should be prepared.
(2) Preoperative enhanced CT examination to determine the size, location and number of lesions.
(3) Liver function and routine blood tests, AFP or CEA, etc.
(4) Fully introduce and explain the treatment procedure and complications to the patient, and obtain consent approval and signature from the patient and family.
(5) Patients should fast for more than 6h, perform analgesic valium and local anesthesia so that patients can better cooperate.
4. Judgment of therapeutic effect
(1) AFP: For those with high AFP before microwave/RF ablation of primary liver cancer, whether AFP is reduced to normal range is an important sign to judge complete tumor necrosis after ablation. If AFP turns negative and maintains for a period of time, and then becomes positive again, the possibility of recurrence or metastasis should be highly alerted.
(2) Ultrasonography: Color Doppler flow imaging technology can sensitively display the blood flow signal around and inside the tumor; energy Doppler ultrasound can continuously and dynamically display the trophoblastic vessels of the tumor, which can more comprehensively display the changes of tumor blood flow distribution before and after treatment, and has greater clinical application value for the judgment of ablation efficacy of liver cancer. Ultrasonography can make timely judgment on the extent of coagulation and the presence or absence of residual blood flow in the tumor to decide whether to terminate the treatment. It can also accurately guide the placement of microwave electrodes in the residual tumor site, which has the incomparable application value of CT and MRI.
(3) Intensive CT or MRI examination: Spiral CT plays an important role in judging the scope of ablation, whether there is residual cancer and whether it recurs after treatment. Immediately after ablation of hepatocellular carcinoma, if coagulative complete necrosis occurs, CT plain scan shows a well-bounded, homogeneous hypodense area, and enhancement scan shows no enhancement in all phases, while very thin circumferential enhancement can be seen in the periphery, at this time, the necrotic range of treatment is larger than the range of lesions before treatment. MRI is more accurate in determining the activity or inactivity of tumor and less harmful to human body.