Primary liver cancer is one of the most common malignant tumors in clinical practice, and the global incidence rate is increasing year by year and has exceeded 626,000/year, ranking 5th among malignant tumors; deaths are close to 600,000/year, ranking 3rd among tumor-related deaths.
The death rate is close to 600,000/year, ranking 3rd in tumor-related deaths. China is a country with high incidence of liver cancer, and currently, the number of incidences in China accounts for about 55% of the world; 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, and early detection and active treatment are of great importance. At present, there are many international guidelines for the treatment of liver cancer, including: (1) National Comprehensive Cancer Network (NCCN) clinical practice guidelines for liver cancer; (2) American Association for the Study of Liver Diseases (AASLD) HCC
In August 2009, the American Veterans Affairs Hepatitis C Y Source Center (HCRC) released the clinician’s guideline “Diagnosis and Treatment of Hepatocellular Carcinoma”, and the first “Expert Consensus on Standardized Diagnosis and Treatment of Primary Liver Cancer” in China was also released in July 2009. The above guidelines are summarized in this article as follows. I. Screening of liver cancer Screening of liver cancer should be based on evidence-based medical evidence, emphasizing early screening and early surveillance, and currently the two main items used for screening include serum alpha-fetoprotein (AFP) and liver ultrasonography. However, since the specificity and sensitivity of these two tests are low, relying on these two tests alone is not sufficient. For men older than 35 years of age, those with hepatitis B virus (HBV) and/or hepatitis C virus (HCV) infection, and those at high risk for alcoholism, screening is generally performed every 6 months. For
AFP >400ug/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
CT and/or magnetic resonance imaging (MRI) should be performed if this can be ruled out. If AFP is elevated but does not reach the diagnostic level, in addition to excluding the above-mentioned conditions that may cause AFP
If AFP is elevated but does not reach the diagnostic level, in addition to ruling out the above-mentioned conditions that may cause an increase in AFP, the dynamics of AFP should be closely followed, the interval between ultrasound examinations should be shortened to 1 to 2 months, and CT and/or MRI should be performed when needed.
CT and/or MRI should be performed when needed. If hepatocellular carcinoma is suspected on ultrasound and cannot be confirmed, digital subtraction angiography (DSA) with iodine oil in the hepatic artery is recommended and entered into the diagnostic process (see below). Diagnosis of hepatocellular carcinoma Diagnostic criteria of hepatocellular carcinoma include pathological diagnostic criteria and clinical diagnostic criteria. The diagnostic methods include serum tumor marker AFP test, imaging examination (including ultrasound, CT, MRI and DSA) and pathological histological examination.
etc.) and pathological histological examination (mainly liver tissue biopsy). The British Society of Gastroenterology (BSG) guidelines suggest that for patients with cirrhosis, the presence of cirrhosis should be determined first, followed by a 2 cm occupancy size threshold to begin the diagnostic process; while for non-cirrhotic patients, the AFP
level to guide the diagnostic process for non-cirrhotic patients. Internationally, the diagnostic process of the American Association for the Study of Liver Diseases (AASLD) is currently applied more often, with occupancy <1
cm, 1 to 2 cm and >2 cm, differentiating between the occupancy and the diagnostic process, with emphasis on early diagnosis. Early diagnosis of primary liver cancer is crucial. From the 20
century, the early diagnosis of liver cancer has been greatly facilitated by the application of serum alpha-fetoprotein (AFP), real-time ultrasonography, CT, MRI and PET-CT since the 1970s to 1980s. As the early diagnosis rate has increased significantly, early diagnosis is directly related to the treatment outcome and prognosis of patients. As far as early diagnosis is concerned, full attention should be paid to patients’ background of liver disease. In China, 95% of liver cancer patients have background of hepatitis B virus (HBV) infection, 10% have 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
The following risk groups should be of particular concern: middle-aged and older men with high HBV carriers, HCV infected patients, HBV and HCV co-infected patients, alcoholics, co-infected diabetics, and those with a family history of liver cancer. After the age of 35-40 years, these people should undergo regular screening every 6 months (including serum AFP
When there is an increase in AFP or an “occupying lesion” in the liver area, the patient should immediately enter the diagnostic process and be closely monitored to make an early diagnosis. The American Association for the Study of Liver Diseases (AASLD) diagnostic process (see later) There are many staging methods for liver cancer, including Barcelona Clinical Liver Cancer (BCLC) staging, Italian Liver Cancer Staging (CLIP) and Japanese Okuda staging. AASLD
The Barcelona Clinical Liver Cancer (BCLC) staging and treatment strategy is adopted, 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. The US Veterans Affairs Hepatitis C Y Source Center (HCRC) has slightly modified the BCLC staging method and published it in May 2009. 1. very early stage: single tumor <2cm, PST 0, Child-Pugh A. 2. early stage: single tumor 2-5cm, or 3 tumors, largest tumor <3cm, PST 0-2, Child-Pugh A/B. 3. intermediate stage: multiple tumors or single tumor >5cm, PST 0, Child-Pugh A/B. 4. intermediate stage: multiple tumors or single tumor >5cm, PST 0, Child-Pugh A/B. 5. Child-Pugh A/B. 4. Advanced stage: Involvement of portal system, local lymph node metastasis in liver portal area or distant metastasis of tumor, Child-Pugh A/B. 5. Terminal stage: PST>2, Child-Pugh C. Treatment of hepatocellular carcinoma There are many treatment options for hepatocellular carcinoma, but the efficacy of some treatment options lacks evidence-based medicine. The stage of liver cancer is the main factor affecting the efficacy and prognosis, and different treatment options should be selected according to the stage of liver cancer; in addition, the choice of treatment options is also related to the medical conditions of local hospitals. According to the stage of liver cancer, there are six treatment options recommended by the US Veterans Affairs Hepatitis C Y Source Center (HCRC), including surgery, transhepatic artery embolization chemotherapy, radiofrequency ablation, anhydrous alcohol injection, sorafenib systemic chemotherapy, and liver transplantation. Surgical treatment occupies an important position in the treatment of hepatocellular carcinoma, but the role of surgical resection has certain limits because: (1) hepatocellular carcinoma is highly malignant and highly susceptible to early dissemination and metastasis; (2) primary hepatocellular carcinoma in China is mostly accompanied by severe cirrhosis and there is often liver function loss; (3) a significant proportion of primary hepatocellular carcinoma occurs in multiple centers; and (4) patients are often in the middle and late stages when they are diagnosed. Therefore, the low resection rate and high recurrence rate are the key constraints to the surgical treatment of liver cancer. In recent years, comprehensive treatment with optimal combination of surgical treatment and various non-surgical treatment methods has been increasingly developed as a new way to further improve the efficacy of hepatocellular carcinoma. Interventional therapy is the preferred non-surgical treatment method, and the main means of radio-interventional treatment for liver cancer is hepatic artery chemoembolization. For hepatocellular carcinoma that cannot be resected radically, the preferred non-surgical treatment method is hepatic artery chemoembolization.