Primary liver cancer is one of the three major fatal diseases in China. After years of exploration, a more scientific treatment plan has been formed for its treatment, and in 2012, the Ministry of Health of China issued the “Standard for the Treatment of Primary Liver Cancer” for liver cancer treatment.
However, the current status quo of liver cancer treatment is rather confusing. Due to the influence of many factors, the medical level of different hospitals varies, and patients are eager to seek medical treatment, often the same liver cancer patient is seen in different hospitals or by different doctors in the same hospital, but receives very different treatment plans, and patients are at a loss as to who is right and who is wrong. In view of this situation, I would like to discuss my views on the treatment of liver cancer with the “treatment standard” issued by the Ministry of Health and some of my clinical experiences.
I. The treatment of early and mid-stage liver cancer is recognized as the first choice of surgical treatment at home and abroad.
Surgical treatment for liver cancer mainly includes the following three options: liver resection; liver transplantation; radiofrequency treatment for liver cancer. The specific choice should be based on the specific conditions of the patient, and it is also a test of the comprehensive ability and quality of a doctor.
For early to mid-stage liver cancer combined with moderate to severe cirrhosis, liver transplantation is the first choice, followed by radiofrequency treatment. Since patients with moderate to severe cirrhosis cannot withstand the trauma of liver resection and will suffer from complications of liver failure such as jaundice and ascites after surgery, which may even lead to death, such patients are not suitable for liver resection.
Second, liver transplantation is the best treatment for end-stage liver disease.
The implementation of liver transplantation is not limited by the patient’s poor liver function. Liver transplantation can not only remove the tumor to the maximum extent, but also remove the soil of recurrence of liver cancer (cirrhosis), eliminate the risk of rupture and bleeding of esophageal vein due to portal hypertension, restore the normal liver function of patients, and provide favorable conditions for further treatment of liver cancer. Therefore, liver transplantation is the first choice of treatment because of its “multi-functional” effect.
After decades of development, liver transplantation has become mature in China and has reached the advanced level in foreign countries. The 10-year survival rate after liver transplantation for benign liver disease has reached more than 70%, which is the best efficacy among all large organs transplanted so far.
Since the first liver transplantation in April 2003, our department has completed more than 150 liver transplants for liver cancer, and the longest survival has been nearly 10 years, with a good survival status and an overall 5-year survival rate of 82% for liver cancer, which is among the most advanced in China.
However, liver transplantation also has “bottleneck” problems.
First of all, there is an extreme shortage of liver donor sources, while there are many patients, about 89 million “hepatitis B” carriers in China, and about 300,000 new cases of liver cancer every year, accounting for more than 50% of the world.
Incomplete data shows that the ratio of “donor to recipient” for organ transplantation in China is 1:150, therefore, whether a patient who needs liver transplantation treatment can wait for a liver source is purely based on “luck”.
Secondly, the cost of liver transplantation is relatively high. Although liver transplantation has entered the scope of “medical insurance” reimbursement, a large part of the cost still needs to be borne by individuals, which is not affordable by every family.
In addition, liver transplantation is a large, traumatic and relatively risky procedure compared to ordinary hepatobiliary surgery, which is not something every potential liver transplant patient’s family is willing to accept. Although all domestic hospitals with liver transplantation qualification can carry out liver transplantation, the level of each liver transplantation center is still “uneven”, and the technical level of the liver transplantation center has a certain influence on the long-term survival rate after transplantation.
Radiofrequency ablation is an important alternative treatment for liver cancer that cannot be removed surgically.
For patients with early to mid-stage liver cancer who cannot choose liver transplantation and combined with moderate to severe cirrhosis, radiofrequency treatment becomes a good choice. Radiofrequency treatment is mainly applicable to tumors below 8 cm in diameter, and for some patients with tumors between 3 and 5 cm, the treatment effect can achieve similar effect as surgical resection.
Radiofrequency is essentially a kind of physical therapy, which is inserted into the tumor through a specially designed radiofrequency needle via penetration, which is converted into high temperature after conducting electricity and kills the tumor through high temperature.
There are various methods of radiofrequency penetration, which can be guided by B-ultrasound, CT, open abdomen or laparoscopic guidance, and the specific method of guidance should be determined by experienced physicians depending on the size and location of the tumor.
Radiofrequency has the characteristics of minimally invasive, fast recovery after surgery, low risk and low cost, which is especially suitable for small liver cancer patients with moderate to severe cirrhosis. Since 1999 (the earliest introduction in East China), our department has applied this device to treat liver cancer, and has completed nearly 3,000 cases so far, with the longest survival reaching more than 10 years.
However, radiofrequency treatment also has certain limitations. For tumors with diameter above 5 cm or close to large blood vessels and hepatic hilum, the effect of radiofrequency treatment is often not so satisfactory because sometimes there may be missed, or because the heat close to large blood vessels is often carried away by blood, so the local temperature cannot reach the level of killing the tumor, and the tumor located in the first hepatic hilum may even accidentally injure the biliary tract and cause biliary complications. Therefore, for this part of the tumor, other methods such as TACE should be used in combination with the treatment.
For early to mid-stage liver cancer with mild cirrhosis or without liver cancer, surgical resection is preferred.
Compared with liver transplantation, hepatectomy has the characteristics of low cost, low risk and fast recovery, which are widely used in China.
After more than 100 years of development, liver resection has changed from irregular hepatectomy and regular hepatectomy in the last century to precise hepatectomy now.
In recent years, with the advancement of liver transplantation, especially in vivo liver transplantation, some fine techniques applied in in vivo liver transplantation have been widely used in liver resection, such as: ICG determination of liver reserve function, DDG liver volume determination, CUSA knife and intraoperative ultrasound application, etc., which have promoted the gradual transformation of liver resection from traditional rough large liver resection to precise liver resection. The application of precision hepatectomy has resulted in less trauma, fewer complications and faster postoperative recovery for patients undergoing hepatectomy.