医学课件：肝细胞癌(英文版).ppt

Hepatocellular carcinomaEpidemiology HCC is the seventh most common cancer worldwide, and the third leading cause of cancer-related deaths. More than 600,000 new cases worldwide annually (50% in China) Over 80% of HCCs occur in developing countries sub-Saharan Africa, southeast Asia, and east Asia Incidence decreased in developing countries and increased in developed countriesYang JD, et al. Nature Rev 2010Global variation in incidence of HCCYang JD, et al. Nature Rev 2010Etiology Hepatitis B: 50% HCC attributed to HBV worldwide Around 100 times higher for incidence of HCC in carriers than non carriers Hepatitis C: leading cause of HCC in Western countries and Japan Aflatoxin B: synergistic factor with HBV in China and sub-Saharan Africa Alcoholic liver disease: second most common risk factor for HCC after HCV in USA Nonalcoholic steatohepatitis (NASH): an emerging risk factor in developed countriesPrevention Vaccination of HBV Reduced HCC incidence after universal vaccination of newborn babies Lamivudine treatment reduced incidence of HCC in hepatitis B or resultant cirrhosis Prevention of HCV transmission No vaccination for HCV Infection control measures in high risk practices (screening blood donors, use of disposable needles, thorough sterilization of surgical instruments) Interferon and ribavirin for hepatitis CPathology of HCC Differentiation Edmondson grade: I, II, III, IV Portal vein invasion Micro vessel, macro vessel (portal vein, hepatic vein, Inferior vena cava) Metastasis Distant metastasis: lung, lymph nodule, bone, adrenal gland, brain)Tumor markers Alpha-fetoprotein (AFP) HCC: 60% 70% with elevated AFP Others: Active Hepatitis, liver cirrhosis Liver metastasis: Gastric cancer, pancreatic cancer, kidney cancer, embryonic tumors des- -carboxy prothrombin (DCP)Imagines Ultrasonography Dynamic computed tomography (CT) Magnetic resonance imagine (MRI) AngiographySurveillance of HCC Individuals high risk for HCC Hepatitis men over 40 years, women over 50 years Patients with persistently or intermittently elevated alanine transaminase (ALT)levels Liver cirrhosis Hepatitis B or C related Alcoholic liver disease Hemochromatosis Primary biliary cirrhosis How to carry out the screening Ultrasonography in combination with serum HCC marker, alpha-fetoprotein (AFP), every 6 monthsDiagnosis American Association for the study of liver Diseases (AASLD) Lesion 1.0cm, with HCC features (enhancement in artery phase and washout in venous phase) on one of Dynamic imagines (CT or MRI) Biopsy Diagnosis of HCCBruix J and Sherman M, Hepatology 2011Diagnosis of HCC Liver cirrhosis CT/MRI Or biopsyStaging systems Barcelona Clinic liver Cancer (BCLC) Cancer of the liver Italian Program (CLIP) TNM (tumor, node and metastasis) Okuda Japanese Integrated staging score (JIS) systemsBCLC stageBruix J and Llovet JM, Lancet 2009Differential diagnosis Liver metastasis Colorectal, pancreatic, breast, lung; Intrahepatic cholangiocarcinoma Angioma Liver cysts Liver Abscess TreatmentSurgical treatment Surgical resection liver transplantationTransarterial chemoembolizaionLocal ablation Percutaneous ethanol injection (PEI) Radiofrequency ablation (RFA)RadiationSyctemic therapyChemotherapy, immunotherapy, molecular target therapySorafenib Sorafenib in advanced HCCMedian sur 6.5m vs 4.2mP=0.014Median time to progress 2.8m vs 1.4mP=0.0005Cheng AL et al. Lancet Oncol 2009Prognosis Tumor stage Size, nodules, portal vein involvement, metastasis Biomarkers Liver function Child-Pugh ECOG performanceThanks UltrasonographyMRIT1WT2WArtery phaseVenous phaseCTNon enhancement, Enhancement in artery phase wash out in venous phaseangiographyPancreatic cancer metastasis to the liverIntrahepatic cholangiocarcinomaangiomaLiver cystSurgical resection n 5-y OS transplantation 468 75.7% surgical resection samll liver cancer 5059 57.0%large liver cancer 4860 30.3%Long-term survival of HCC treated with surgical resection and transplantation (1958-2009)Transarterial chemoembolizationPercutaneous ethanol injectionRadiofrequency ablationRFA for HCCSmall HCC treated with radiofrequency ablation（zhongshan hospital n=864)5cm: Medial survival 42m 5-year survaval rate: 34.7%3cm: Medial survival 62m 5-year survval rate：50.6%P0.0001