肝癌的局部治療.ppt

肝癌局部治療 內容提要Image guidedpercutaneousablationisestablishedasthebesttherapeuticchoiceforpatientswithearly stageHCCwhensurgicalresectionorlivertransplantationareprecluded 影像介導的經皮消融術是無法進行手術和肝移植的病人最佳的治療方法 TACEisthestandardofcareforpatientswithintermediate stagedisease 經肝動脈化療栓塞 TACE 是中期肝癌患者的標準治療方法 TheBarcelonaClinicLiverCancer BCLC classificationhasemergedinrecentyearsasthestandardclassificationthatisusedforclinicalmanagementofpatientswithHCC 目前BCLC分類是肝癌患者臨床分期的標準方法 Very Early StageHCC超早期肝癌Invery early stageHCC thepresenceofasolitarysmallnodule smallerthan2cmindiameter inpatientswithChild PughclassAdisease theabsenceofmicrovascularinvasionanddisseminationofferthehighestlikelihoodofcure 超早期肝癌直徑小于2cm Child Pugh評分A 無血管侵犯和遠處轉移 最有可能被治愈 AccordingtotheBCLCstagingsystem thesepatientscanbeofferedsurgicalresectioniftheyarenoncirrhoticoriftheyhavecirrhosisbutstillhavewell preservedliverfunction normalbilirubinlevel andanabsenceofclinicallysignificantportalhypertension Suchpatientswillnotdecompensateafterresectionandhavea5 yearsurvivalrateofbetterthan75 對BCLC分類中的超早期肝癌 如果沒有肝硬化 或雖然有肝硬化但肝功能尚可 膽紅素水平正常 沒有明顯門脈高壓 則可以考慮手術切除 這類病人術后不會引發(fā)代謝失常 5年生存率大于75 Anatomicresection definedastheenblocremovalofaportionofliversuppliedbyamajorbranchoftheportalveinandthehepaticartery isconsideredthepreferredsurgicaltechnique becauseittheoreticallyallowstheeradicationofintrahepaticmetastasesofHCC resultinginabetteroutcomeascomparedwithnonanatomicresection 解剖切除 指整塊切除由門脈及肝動脈主要分支供血的肝組織 被認為是更好的手術方式 因為其理論上可將潛在肝內轉移灶一起切除 However severeimpairmentofliverfunctionand possibly liverfailure couldfollowsurgicalintervention 但過多切除肝組織可能造成肝功能不全 甚至肝衰竭 對于超早期肝癌 手術和消融效果類似 但適用于不同病人RFablation small 2cm centrallylocated消融適合于小 位置深的病灶resection subcapsularorperivascularlocation adjacenttothegallbladder手術適合于鄰近包膜 血管或膽囊窩的病灶 這些地方消融并發(fā)癥高 病灶清除不干凈 超早期肝癌患者接受射頻消融治療前 動脈期明顯強化 a 門脈期呈相對低密度 并見假包膜 b 治療后 cd 腫塊無強化 范圍較前擴大 Early stageHCC早期肝癌Early stagediseaseincludespatientswithpreservedliverfunction Child PughAandB withsolitaryHCCoruptothreenoduleslessthan3cminsize 早期肝癌指肝功能尚存 Child PughA和B 單個結節(jié) 或三個結節(jié)以內范圍小于3cm Thesepatientscanbeeffectivelytreatedwithresection livertransplantation orpercutaneousablation withthepossibilityoflong termcureand5 yearsurvivalrateestimatesrangingfrom50 to75 這類病人的治療主要包括手術 消融和肝移植 5年生存率約50 70 對早期肝癌 手術切除治療效果似乎比射頻消融更好 但還需更進一步證據 Amongdifferentablativetechniques RFablationiscurrentlyconsideredtobethebesttreatmentoptioninpatientswithearly stageHCC 在不同消融方法中 射頻消融被認為是最有效的 AcombinationofTACEfollowedbyRFablationhasbeenusedtominimizeheatlossduetoperfusionmediatedtissuecoolingandtoincreasethetherapeuticeffectofRFablation 射頻消融前先進行肝動脈化療栓塞比單純射頻消融更有效 射頻消融過程中如果破壞血管 外溢的血液可使局部環(huán)境冷卻 減少對腫瘤細胞的殺傷 而肝動脈化療栓塞可事先栓塞血管 從而隨后的射頻消融更有效 Patientswithasolitarylarge 5cm tumordeservespecialmention Evenifthesepatientscannotbeconsideredtohaveearly stagediseasebecausetheydonotqualifyfortransplantation noupperlimitofsizeforsurgicalresectionappearsintheBCLCflowchart andthesepatientsshouldnotbeexcludedfromsurgicalreferralbecausetheirtumorsaretoolarge Differentablativemodalitiesdonotcurrentlyprovidesufficientvolumeofablationtosuccessfullytreatthesetumors andtheresultsoftransarterialtherapiesasstandalonetreatmentsarehighlyvariableinthisclinicalscenario 對單發(fā)大于5cm腫塊 因為腫塊體積太大 已不適合肝移植 但根據BCLC分類方法 這些病人仍能進行手術切除 消融術很難完整破壞腫瘤 而動脈栓塞等治療的效果則很不確定 ForpatientswithHCCwhoareonthewaitinglistforlivertransplantation BothablationandTACEcanbeappliedatthetimeoflisting 對于等待肝移植的病人 消融和TACE都可以考慮 其他消融方法 有效性有待進一步證實 Microwave MW ablation微波消融ElectromagneticMWsheatmatterbyagitatingwatermoleculesinthesurroundingtissue whichproducesfrictionandheat thusinducingcellulardeathbymeansofcoagulationnecrosis 微波消融利用微波擾亂周圍環(huán)境水分子 制造摩擦和熱量 導致細胞凝固性壞死 ThemainfeaturesofMWtechnology whencomparedwithexistingthermalablationtechnologies includeconsistentlyhigherintratumoraltemperatures largertumorablationvolumes fasterablationtimes andanimprovedconvectionprofile 和其他消融術相比 微波消融溫度更高 時間更短 能用于治療更大體積腫瘤 Asaresult theadvantageofMWoverRFablationisthattreatmentoutcomeislessaffectedbyvesselsinproximitytothetumor 和射頻消融比 微波消融較少受腫瘤血供影響 irreversibleelectroporation IRE 不可逆電穿孔IREisamethodtoinduceirreversibledisruptionofcellmembraneintegritybychangingthetransmembranepotential resultingincelldeathwithouttheneedforadditionalpharmacologicinjury IRE造成膜電位不可以改變 導致細胞死亡IREcreatesasharpboundarybetweenthetreatedanduntreatedareasinvivo 實驗證實IRE可制造銳利邊緣Moreover becauseIREisanonthermaltechnique issuesassociatedwithperfusion mediatedtissuecoolingorheatingarenotrelevant 因為IRE不通過產熱起作用 所以治療效果與腫瘤血供無關 早期肝癌患者接受射頻消融治療前 動脈期明顯強化 a 門脈期呈相對低密度 并見假包膜 b 治療后 cd 腫塊無強化 范圍較前擴大 CombinedRFablationandTACEwithdrug elutingbeadstotreatearly stageHCCina71 year oldmanwithhepatitisC relatedlivercirrhosis a PretreatmentarterialphaseT1 weightedgradient echomagneticresonance MR imageshowshypervascularHCCatdomeofliver b d CTimagesobtainedimmediatelyafterRFablationshowresidualviabletumor b c superiorandlateraltoablationzone arrow while d necrosiswithoutevidenceofresidualviabletumorisseeninferiorly e f Angiogramsshowtreatmentcompletionwithintraarterialinjectionof2mLof100 300 mmdrug elutingbeadsloadedwith50mgofdoxorubicin DCBeads BTG Biocompatibles Farnham England Arrow residualviabletumor g i CTimagesobtained1monthaftertreatmentshowcompleteresponse 射頻消融聯(lián)合肝動脈化療栓塞 化療藥物緩釋顆粒治療早期肝癌射頻消融后少數(shù)腫瘤殘留 箭 進一步行肝動脈化療栓塞 化療藥物緩釋顆粒治療后腫瘤完全清除 Intermediate StageHCC中期肝癌Patientswithintermediate stageHCC ie multinodularHCC relativelypreservedliverfunction absenceofcancer relatedsymptoms andnoevidenceofvascularinvasionorextrahepaticspreadareconsideredcandidatesforTACE 中期肝癌 多結節(jié)性 肝功能尚存 無副癌綜合癥 無血管侵犯及肝外轉移 患者的治療主要為肝動脈化療栓塞 TACE AlthoughTACEimprovessurvivalforpatientswithintermediate stageHCCasawhole notallsuchpatientswillderivesimilarbenefitfromTACEandthatsomemaybenefitfromtreatmentsotherthanTACE 雖然總體上TACE可提高中期肝癌患者的生存率 但對不同病情的患者效果各異 有時需要考慮其他更好的治療方法 TheriskofTACE associatedcomplicationsmaybegreaterinpatientswithmoreextensivediseaserequiringnonselectiveembolization withunfavorablevascularanatomy andwithpoorresidualliverfunction TACEisnotsuitable ingeneral forpatientswithdecompensatedlivercirrhosis definedasChild PughB score 8 withascitesand orjaundice owingtothehighriskofserioustreatment relatedcomplications TACE治療存在風險 對于嚴重病例常需廣泛栓塞 這可能破壞過多肝組織 導致肝功能無法代償 并可能導致嚴重并發(fā)癥 失代償型肝硬化 Child PughB 評分 8 腹水 黃疸 和血管解剖異常等因素也影響治療效果 其他方法 TACEwithdrug elutingbeads TACE 化療藥緩釋顆粒systemictherapywithatargetedagent 全身靶向藥物治療Radioembolization intraarteriallyinjectedmicrospherescoatedwithyttrium90 90Y 放療性栓塞 經肝動脈注入包被90Y 放射原 的微球體 Advanced StageHCC晚期肝癌Patientswithadvanced stageHCCincludethosewhopresentwithcancersymptomsand orvascularinvasionorextrahepaticspread Overall thesepatientshaveashorterlifeexpectancy 50 survivalat1year 晚期肝癌 有癥狀 血管侵犯 肝外轉移 患者1年生存率約50 AccordingtotheBCLCtreatmentstrategy systemictherapywiththemultikinaseinhibitorsorafenibisconsideredthetherapyofchoiceforpatientswithadvancedHCC BCLC建議對晚期肝癌患者施行索拉非尼 激酶抑制劑 可抑制血管生成和細胞增殖 全身化療 Itisdebatableifpatientsclassifiedashavingadvancedstagediseasewhohavemildlyimpairedperformancestatusbutwithuninodularormultinodulardiseasewithoutvascularinvasionandextrah