肝癌的局部治療.ppt

肝癌局部治療 內(nèi)容提要Image guidedpercutaneousablationisestablishedasthebesttherapeuticchoiceforpatientswithearly stageHCCwhensurgicalresectionorlivertransplantationareprecluded 影像介導(dǎo)的經(jīng)皮消融術(shù)是無法進(jìn)行手術(shù)和肝移植的病人最佳的治療方法 TACEisthestandardofcareforpatientswithintermediate stagedisease 經(jīng)肝動(dòng)脈化療栓塞 TACE 是中期肝癌患者的標(biāo)準(zhǔn)治療方法 TheBarcelonaClinicLiverCancer BCLC classificationhasemergedinrecentyearsasthestandardclassificationthatisusedforclinicalmanagementofpatientswithHCC 目前BCLC分類是肝癌患者臨床分期的標(biāo)準(zhǔn)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(píng)分A 無血管侵犯和遠(yuǎn)處轉(zhuǎn)移 最有可能被治愈 AccordingtotheBCLCstagingsystem thesepatientscanbeofferedsurgicalresectioniftheyarenoncirrhoticoriftheyhavecirrhosisbutstillhavewell preservedliverfunction normalbilirubinlevel andanabsenceofclinicallysignificantportalhypertension Suchpatientswillnotdecompensateafterresectionandhavea5 yearsurvivalrateofbetterthan75 對(duì)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(shù)切除 這類病人術(shù)后不會(huì)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(dòng)脈主要分支供血的肝組織 被認(rèn)為是更好的手術(shù)方式 因?yàn)槠淅碚撋峡蓪撛诟蝺?nèi)轉(zhuǎn)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(duì)于超早期肝癌 手術(shù)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(shù)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(dòng)脈期明顯強(qiáng)化 a 門脈期呈相對(duì)低密度 并見假包膜 b 治療后 cd 腫塊無強(qiáng)化 范圍較前擴(kuò)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(gè)結(jié)節(jié) 或三個(gè)結(jié)節(jié)以內(nèi)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(shù) 消融和肝移植 5年生存率約50 70 對(duì)早期肝癌 手術(shù)切除治療效果似乎比射頻消融更好 但還需更進(jìn)一步證據(jù) Amongdifferentablativetechniques RFablationiscurrentlyconsideredtobethebesttreatmentoptioninpatientswithearly stageHCC 在不同消融方法中 射頻消融被認(rèn)為是最有效的 AcombinationofTACEfollowedbyRFablationhasbeenusedtominimizeheatlossduetoperfusionmediatedtissuecoolingandtoincreasethetherapeuticeffectofRFablation 射頻消融前先進(jìn)行肝動(dòng)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(duì)腫瘤細(xì)胞的殺傷 而肝動(dòng)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(duì)單發(fā)大于5cm腫塊 因?yàn)槟[塊體積太大 已不適合肝移植 但根據(jù)BCLC分類方法 這些病人仍能進(jìn)行手術(shù)切除 消融術(shù)很難完整破壞腫瘤 而動(dòng)脈栓塞等治療的效果則很不確定 ForpatientswithHCCwhoareonthewaitinglistforlivertransplantation BothablationandTACEcanbeappliedatthetimeoflisting 對(duì)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(jìn)一步證實(shí) 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(dǎo)致細(xì)胞凝固性壞死 ThemainfeaturesofMWtechnology whencomparedwithexistingthermalablationtechnologies includeconsistentlyhigherintratumoraltemperatures largertumorablationvolumes fasterablationtimes andanimprovedconvectionprofile 和其他消融術(shù)相比 微波消融溫度更高 時(shí)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(dǎo)致細(xì)胞死亡IREcreatesasharpboundarybetweenthetreatedanduntreatedareasinvivo 實(shí)驗(yàn)證實(shí)IRE可制造銳利邊緣Moreover becauseIREisanonthermaltechnique issuesassociatedwithperfusion mediatedtissuecoolingorheatingarenotrelevant 因?yàn)镮RE不通過產(chǎn)熱起作用 所以治療效果與腫瘤血供無關(guān) 早期肝癌患者接受射頻消融治療前 動(dòng)脈期明顯強(qiáng)化 a 門脈期呈相對(duì)低密度 并見假包膜 b 治療后 cd 腫塊無強(qiáng)化 范圍較前擴(kuò)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(dòng)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(jìn)一步行肝動(dòng)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(jié)節(jié)性 肝功能尚存 無副癌綜合癥 無血管侵犯及肝外轉(zhuǎn)移 患者的治療主要為肝動(dòng)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(duì)不同病情的患者效果各異 有時(shí)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(fēng)險(xiǎn) 對(duì)于嚴(yán)重病例常需廣泛栓塞 這可能破壞過多肝組織 導(dǎo)致肝功能無法代償 并可能導(dǎo)致嚴(yán)重并發(fā)癥 失代償型肝硬化 Child PughB 評(píng)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(jīng)肝動(dòng)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(zhuǎn)移 患者1年生存率約50 AccordingtotheBCLCtreatmentstrategy systemictherapywiththemultikinaseinhibitorsorafenibisconsideredthetherapyofchoiceforpatientswithadvancedHCC BCLC建議對(duì)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(xì)胞增殖 全身化療 Itisdebatableifpatientsclassifiedashavingadvancedstagediseasewhohavemildlyimpairedperformancestatusbutwithuninodularormultinodulardiseasewithoutvascularinvasionandextrah