Vilarinho Sílvia, Taddei Tamar
Department of Internal Medicine, Section of Digestive Diseases, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, PO Box 208019, New Haven, CT, 06520-8019, USA,
Curr Treat Options Gastroenterol. 2015 Jun;13(2):219-34. doi: 10.1007/s11938-015-0049-8.
Hepatocellular carcinoma (HCC) is the fastest growing malignancy in the USA, and its prognosis remains poor with a 5-year survival around 12 %. Clinical data demonstrate that 85 % of cases occur in individuals with underlying cirrhosis and only 15 % develop in non-cirrhotic livers. Therefore, American and European guidelines recommend routine HCC screening for high-risk individuals (patients with cirrhosis) with abdominal ultrasound every 6 months. Once a lesion is identified or suspected on ultrasound, dynamic imaging is then indicated. The diagnosis of HCC is established in a patient with cirrhosis when a lesion measures at least 1 cm in diameter and demonstrates arterial enhancement and portal venous washout on contrast-enhanced computerized tomography or magnetic resonance imaging. Indeterminate lesions should be followed with surveillance imaging or further investigated with biopsy according to the level of suspicion for malignancy. Given the clinical, pathological, and molecular heterogeneity of HCC, there are multiple therapeutic modalities available. These may be curative, such as surgical resection, liver transplantation, and local ablation, or palliative, such as catheter-directed therapies (transarterial chemo, radio, or bland embolization), and systemic therapy (sorafenib). Patients with a single lesion, good performance status, and preserved liver synthetic function should be offered curative surgical resection or ablation therapy. Patients with HCC and decompensated liver disease should be evaluated and listed for liver transplantation. For unresectable disease or tumor burden precluding transplantation or curative ablation, palliative therapeutic modalities should be offered. Sorafenib is indicated for patients with vascular invasion and/or extra-hepatic metastasis if the estimated life expectancy is more than 3 months. Systemic internal radiation therapy using yttrium-90 microspheres in cases of multifocal bi-lobar disease and/or portal vein occlusion is an emerging therapy. Best supportive care is recommended for patients who lack the hepatic reserve to tolerate therapy.
肝细胞癌（HCC）是美国增长最快的恶性肿瘤，其预后仍然很差，5年生存率约为12%。临床数据表明，85%的病例发生在患有潜在肝硬化的个体中，只有15%发生在非肝硬化肝脏中。因此，美国和欧洲的指南建议对高危个体（肝硬化患者）每6个月进行一次腹部超声的常规HCC筛查。一旦在超声检查中发现或怀疑有病变，就需要进行动态成像检查。当肝硬化患者的病变直径至少为1厘米，并且在对比增强计算机断层扫描或磁共振成像上显示动脉期强化和门静脉期廓清时，即可确诊为HCC。对于不确定的病变，应根据对恶性肿瘤的怀疑程度进行监测成像随访或通过活检进一步检查。鉴于HCC在临床、病理和分子方面的异质性，有多种治疗方式可供选择。这些治疗方式可能是根治性的，如手术切除、肝移植和局部消融，也可能是姑息性的，如导管导向治疗（经动脉化疗、放疗或单纯栓塞）和全身治疗（索拉非尼）。对于单个病灶、身体状况良好且肝脏合成功能保留的患者，应提供根治性手术切除或消融治疗。HCC合并肝功能失代偿的患者应接受评估并列入肝移植名单。对于不可切除的疾病或肿瘤负荷排除移植或根治性消融的患者，应提供姑息性治疗方式。如果预期寿命超过3个月，索拉非尼适用于有血管侵犯和/或肝外转移的患者。对于多灶性双叶疾病和/或门静脉闭塞的病例，使用钇-90微球进行全身内放射治疗是一种新兴的治疗方法。对于缺乏肝脏储备能力耐受治疗的患者，则建议给予最佳支持治疗。
