Tang Z Y, Yu Y Q, Zhou X D, Yang B H, Lin Z Y, Lu J Z, Ma Z C, Ye S L, Liu K D
Liver Cancer Institute, Shanghai Medical University, People's Republic of China.
Gan To Kagaku Ryoho. 1997 May;24 Suppl 1:126-33.
In the author's institution, 2254 patients with hepatocellular carcinoma (HCC) have been treated during 1958-1994. The overall 5-year survival increased from 5.4% (1958-1970), to 11.9% (1971-1982), to 46.2% (1983-1984), which correlated well with the increasing proportion of small HCC in the series (2.6%, 12.1%, and 33.4%, respectively); with the increasing percentage of limited resection (3.1%, 32.2%, and 58.3%); with the increasing number of re-resections for recurrence (0, 27, and 114 patients); and with the increasing number of second stage resections (0, 5, and 67 patients). In our institution, surgical approaches that resulted in significantly prolonging survival included: small HCC resection, re-resection, and cytoreduction followed by sequential resection for initially unresectable HCC. Experience in these 3 aspects suggests: (a) Small HCCs are mainly found by screening using AFP and ultrasonography (US) in a high risk population, and limited resection is the best treatment in patients with compensated liver cirrhosis, the 5-year survival after resection being 62.9% (n = 549). (b) Postoperative monitoring using AFP/US every 2-3 months for 5-10 years after curative resection is needed to detect subclinical recurrence. Limited re-resection is indicated for liver recurrence less than 3 nodules, and lung lobectomy is of proven merit to prolong survival for solitary lung metastasis. Re-resection of subclinical recurrence has resulted in a 10-20% further increase in 5-year survival after curative resection. (c) Palliative surgery other than resection such as hepatic artery ligation (HAL) and cannulation with arterial infusion (HAI), cryosurgery, etc. are superior to palliative resection with residual cancer. (d) Cytoreduction and sequential resection have provided hope for localized unresectable HCC, particularly in the right cirrhotic liver. Multimodality combination treatments such as HAL+HAI+radioimmunotherapy/regional radiotherapy are acceptable cytoreductive therapies. Repeated transcatheter hepatic arterial chemoembolization (TACE) is an alternative nonsurgical approach. Sequential resection is important to eradicate residual cancer after cytoreduction. The 5-year survival of 72 patients with cytoreduction and sequential resection for initially unresectable HCC was 62.1% and resulted in improving 5-year survival in the entire series of unresectable HCC over the 3 periods from 0% to 7.4% to 25.7%, respectively. However, multicentric origin and tumor invasiveness are two major targets to be studied in the control of recurrence and metastasis.
在作者所在机构，1958年至1994年间共治疗了2254例肝细胞癌（HCC）患者。总体5年生存率从1958 - 1970年的5.4%，提高到1971 - 1982年的11.9%，再到1983 - 1984年的46.2%，这与该系列中小肝癌比例的增加（分别为2.6%、12.1%和33.4%）密切相关；与有限切除比例的增加（3.1%、32.2%和58.3%）相关；与复发后再次切除的患者数量增加（0、27和114例）相关；以及与二期切除患者数量增加（0、5和67例）相关。在我们机构，能显著延长生存期的手术方法包括：小肝癌切除、再次切除，以及对初始不可切除的HCC进行细胞减灭术随后序贯切除。在这三个方面的经验表明：（a）小肝癌主要通过在高危人群中使用甲胎蛋白（AFP）和超声检查（US）进行筛查发现，对于代偿期肝硬化患者，有限切除是最佳治疗方法，切除术后5年生存率为62.9%（n = 549）。（b）根治性切除术后需要每2 - 3个月使用AFP/US进行5 - 10年的术后监测以检测亚临床复发。对于肝内复发少于3个结节的情况，可行有限再次切除，对于孤立性肺转移，肺叶切除术已被证明有利于延长生存期。亚临床复发的再次切除使根治性切除术后的5年生存率进一步提高了10 - 20%。（c）除切除以外的姑息性手术，如肝动脉结扎术（HAL）和动脉插管灌注术（HAI）、冷冻手术等，优于有残留癌的姑息性切除术。（d）细胞减灭术和序贯切除为局部不可切除的HCC带来了希望，尤其是在右肝肝硬化患者中。多模式联合治疗，如HAL + HAI + 放射免疫治疗/区域放疗，是可接受的细胞减灭疗法。重复经导管肝动脉化疗栓塞术（TACE）是一种替代性非手术方法。序贯切除对于细胞减灭术后根除残留癌很重要。72例对初始不可切除的HCC进行细胞减灭术和序贯切除的患者，其5年生存率为62.1%，使整个不可切除HCC系列在三个时期的5年生存率分别从0%提高到7.4%再到25.7%。然而，多中心起源和肿瘤侵袭性是控制复发和转移方面需要研究的两个主要目标。
