肝癌肝切除简评

StephenW

A brief comment on liver resection for hepatocellular carcinoma

    Haifeng Xu and
    Yilei Mao*

+ Author Affiliations

    Department of Liver Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China

    ↵*Corresponding author. Department of Liver Surgery, Peking Union Medical College Hospital, No 1, Shuai Fu Yuan, Dongcheng District, Beijing, CHINA, 100730 Tel: +86 (0) 10 - 6915-6042; Fax: +86 (0) 10-6915-6043; Email: [email protected]

Although only 30–40% of patients with hepatocellular carcinoma (HCC) are eligible for surgery, it remains the most feasible and efficient treatment [1, 2]. The three most important factors that have led to reduce mortality, with a 70% expectation of 5-year survival, are: i) better liver function assessment, ii) understanding of the segmental liver anatomy through more accurate imaging studies and iii) technical advances in surgical procedures [3]. Hepatic resection is the treatment of choice for HCC, especially in non-cirrhotic patients. Major resections can be carried out with low rates of life-threatening complications. Conversely, among patients who have cirrhosis, strict selection criteria are required to avoid treatment-related complications.

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Partial liver resection

In an HCC patient, both tumor size and degrees of histological changes of the underlying parenchyma will considerably influence the indication and the extent of partial liver resection. HCC tumors in patients with normal livers are often large (>10 cm) without vascular invasion and diagnosed when tumors are symptomatic. The only curative treatment is major hepatectomy with lymph node dissection, which is often well tolerated in the absence of underlying liver disease and with good regenerative capacity of the remnant liver. The long-term results of resection of HCC without chronic liver disease are much better than in patients with cirrhosis, with reported 5-year disease-free survival rates as high as 60–65% [4]. Intrahepatic recurrence should be treated whenever possible by repeat resection ablation. Therefore, partial resection in a diseased parenchyma increases risk due to impaired liver regeneration, altered texture of liver parenchyma, portal hypertension and coagulation defects [5]. There is a close relationship between the extent of resection and postoperative risk, which limits the indication of resection in patients with altered liver function and those with large tumors [6]. Indeed, partial resection in patients with diseased liver must follow two contradictory objectives: i) to be curative with resection of the tumor vascular territories and ii) to preserve as much liver parenchyma volume as possible to prevent postoperative liver failure.
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Anatomical resection

The anatomical territory of HCC ranges from sub-segment to lobe, according to the size of the tumor. Intrahepatic metastasis of HCC along the portal vein and the presence of satellite nodules up to 2 cm in size are the basis of anatomical liver resection [7]. Indeed, anatomical resections according to the architecture of the portal vein have the potential to remove undetected cancerous foci (portal vein metastases and satellite nodules) disseminated from the primary gross tumor. Moreover, anatomical resections of small solitary HCC achieve a significantly better overall and disease-free survival rate than limited resections, without increasing postoperative risk [8, 9]. However, the benefit of segmental resection may only become apparent in tumors between 2 and 5 cm in size. Below this size range, the risk of dissemination is considered to be negligible, with efficacy equivalent to local ablative therapy whereas, beyond this size, the majority of patients will already have macroscopic vascular invasion or satellite nodules that will dictate a high incidence of recurrence [10]. In the case of central tumors with undefined vascular territory, some authors have found a lower recurrence rate and better survival with a 2 cm margin, compared with a 1 cm margin [11], whereas other authors have not found differences, categorizing margins as <1 or >1 cm [8]. In fact, a wide margin up to 2 cm is required. It is proven that hepatic resection for HCCs >10 cm in diameter without macroscopic venous invasion is a safe and effective option. Spontaneous rupture of HCC and extension to surrounding structures, such as the diaphragm, the stomach or the colonic flexure, does not represent a contra-indication for resection if negative resection margins are attained. The presence of two or three nodules can be subjected to oncological surgical resection [12]. In selected patients with multifocal tumors, partial resection can be associated with stabilization of contralateral liver nodules by chemo-embolization or radiofrequency ablation [13]. Patients with HCC and tumor thrombus in the vena cava or in the portal trunk tend to have a poorer prognosis [14]. A major vascular involvement is generally associated with large tumors, for which no treatment can be anticipated. Yet it has been shown that, in a selected group of patients with normal liver function and excellent general status, extensive liver resection, associated with removal of the vascular thrombus, could achieve favorable survival results [14]. According to our own experience, anatomical resection, such as right hemihepatectomy or right three lobectomy, is relatively safe in some strictly selected patients.
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Laparoscopic liver resection

Laparoscopic liver resection represents 10–20% of all current liver resections, at least in the USA [15, 16]. Major obstacles for laparoscopic liver resection include a long learning curve, the difficulty of achieving a wide resection margin and performing anatomical resections, as well as technical difficulties in mobilization and parenchymal transection with risk of massive bleeding. The anticipated advantages of laparoscopic liver resection are its less aggressive approach (incision with less pain, fewer pulmonary complications and early recovery), less peritoneal dissection, avoidance of collateral ligation, reduced bleeding, minimal ascites and decreased postoperative liver failure [15]. These postulated factors could expand indications of liver resection in some Child-Pugh class B patients [15]. Moreover, compared with open liver resection, the reduced number of postoperative adhesions after laparoscopic liver resection facilitates subsequent salvage liver transplantation, with decreased morbidity [17]. In China, the suggested liver resection with laparoscopy can currently be performed in segments II, III, IV, V and VI of the liver.

Liver resection is an established treatment for HCC owing to its minimal surgical mortality and improved survival rate. Treatment guidelines for HCC will facilitate decision-making by both patients and physicians at every clinical step. Physicians need to recommend treatment options and allow the patient to choose.

    © The Author(s) 2013. Published by Oxford University Press and the Digestive Science Publishing Co. Limited.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.

StephenW

肝癌肝切除简评

    徐海峰和
    艾磊茂*

+作者所属机构

    肝外科部，北京协和医学院中国医学科学院，北京协和医院，北京，中国

    ↵ *通讯作者。肝脏外科部，北京协和医院， 1号，帅府园，东城区，北京，中国， 100730电话： +86 （0）10 - 6915-6042传真：+86 （0） 10-6915 - 6043 ;电子邮件： [email protected]的

虽然只有30-40％的肝细胞癌（HCC ）患者获手术，它仍然是最可行和有效的治疗[ 1，2 ] 。三个最重要的因素，导致降低死亡率， 5年生存率70％的预期，是：1）更好的肝功能评估， II）肝叶解剖的理解通过更准确的影像学检查及iii ）技术进步在手术过程中[3]。肝切除是治疗肝癌的首选，尤其是在非肝硬化患者。主要可以进行切除率较低的危及生命的并发症。相反，有肝硬化的患者中，都需要严格的选择标准，以避免治疗相关的并发症。

下节
部分肝切除

在肝癌患者中，肿瘤的大小和相关实质的组织学改变的程度将大大影响部分肝切除术适应症和程度。肝癌患者与正常肝脏肿瘤往往较大（ > 10厘米） ，无血管浸润，确诊时肿瘤有症状。唯一的治疗主要是切除淋巴结清扫术，这是通常耐受性良好，没有潜在的肝脏疾病和​​剩余肝脏具有良好的再生能力。没有慢性肝病的肝癌切除的长期业绩远远优于肝硬化患者，报道的5年无病生存率高达60-65％ [4]。肝内复发只要有可能，应被视为重复消融切除。因此，在病变实质增加风险部分切除由于受损肝再生，改变纹理肝实质，门脉高压症和凝血缺陷[5]。有限制的指示切除患者肝功能改变和那些大肿瘤切除及术后风险的程度，有着密切的关系[ 6] 。事实上，部分切除病肝患者必须遵循两个相互矛盾的目标： i）须根治性切除肿瘤血管领土及ii）尽可能多地保留肝实质体积尽可能防止术后肝功能衰竭。
上一节下一节
解剖切除

的解剖领土的HCC范围从子段叶，根据肿瘤的大小。沿门静脉的肝癌和卫星结节的存在下，以2厘米大小的肝内转移解剖肝切除术的基础上[7 ] 。事实上，根据门静脉的体系结构的解剖切除有潜在的删除未检测到的癌病灶（门静脉转移和卫星结节）从主大体肿瘤传播。此外，解剖切除的小孤肝癌实现一个更好的整体和无病生存率较有限的切除，不增加术后风险[8 ， 9] 。然而，段切除的好处可能只会变得明显，在2至5厘米大小的肿瘤。低于这个尺寸范围内，被认为是传播的风险可以忽略不计，相当于局部消融治疗，而超过此大小，多数患者已经将决定高复发率的宏观血管侵犯或卫星结节疗效[ 10 ] 。在中央的肿瘤与未定义的血管领土的情况下，一些作者发现了一个较低的复发率和更好的生存与2公分， 1公分相比[11] ，而其他作者还没有发现差异，分类利润< 1或大于1厘米的[8]。事实上，大幅度可达2厘米是必需的。事实证明，无肉眼静脉浸润> 10厘米，直径为肝癌肝切除是一种安全，有效的选择。自发性破裂肝癌和扩展到周围的结构，如隔膜，胃或结肠弯曲，并不代表禁忌症切除术， ，如果达到负切除。两个或三个结节的存在下可以进行手术切除肿瘤[12] 。部分切除在选择多灶性肿瘤患者，可以稳定对侧肝结节伴有化疗栓塞或射频消融治疗[13] 。与肝癌和腔静脉或门静脉主干癌栓的患者往往预后较差[14] 。一个主要的血管受累通常与大的肿瘤，没有治疗可以预见的。然而，它已经表明，在选定的一组患者肝功能正常，一般状态极佳，广泛的肝切除术，去除血管血栓，可实现良好的生存结果[14] 。根据我们自己的经验，解剖切除术， ，如右半肝切除或右三个肺叶切除，是相对安全的在一些严格选择的患者。
上一节下一节
腹腔镜肝切除术

腹腔镜肝切除表示10-20％的所有电流的肝切除，至少在美国[ 15，16 ] 。腹腔镜肝切除术的主要障碍包括很长的学习曲线，实现了宽边缘切除，并进行解剖切除的难度，以及技术上的困难，动员和实质横断大出血的风险。预期腹腔镜肝切除术的优点是其较激进的做法（切口，痛苦少，减少肺部并发症和早期恢复） ，腹膜剥离少，避免抵押品结扎，减少出血，腹水最小，减少术后肝功能衰竭[15] 。这些假设的因素可能扩大肝切除术的适应症，在一些Child-Pugh分级B级患者[15] 。此外，开放肝切除术相比​​，数量减少术后粘连腹腔镜肝切除后有利于随后打捞肝移植，降低发病率[17]。建议腹腔镜肝切除术在中国，目前可以进行细分II ，III，IV ，V和VI的肝脏。

肝切除术是一种治疗肝癌，由于其最小的手术死亡率和提高生存率。肝癌的治疗指南，将有利于决策的病人和医生都在每一个临床一步。医生需要推荐的治疗方案，让病人选择。

    © （次） 2013 。由牛津大学出版社和消化科学出版有限公司出版。

这是一个开放的分布的条款下的知识共享署名许可（ http://creativecommons.org/licenses/by/3.0/ ） ，允许无限制地重复使用，分配和再现任何媒体的访问文章，提供了原来的工作正确引用。

果农

虽然只有30-40％的肝细胞癌（HCC ）患者获手术，它仍然是最可行和有效的治疗[ 1，2 ] 。三个最重要的因素，导致降低死亡率， 5年生存率70％的预期，是：1）更好的肝功能评估， II）肝叶解剖的理解通过更准确的影像学检查及iii ）技术进步在手术过程中[3]。肝切除是治疗肝癌的首选，尤其是在非肝硬化患者。主要可以进行切除率较低的危及生命的并发症。相反，有肝硬化的患者中，都需要严格的选择标准，以避免治疗相关的并发症。

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