肝癌综合治疗.ppt

肝癌的综合治疗Multidisciplinary Strategies to Management of HCC 复旦大学肝癌研究所 治疗的目的 肿瘤缩小 改善生命质量 延长生存 QALY HCC 治疗选择 早期HCC 外科切除（肝部分切除） 肝移植 经皮毁损（PEI，RFA，HIFU，冷冻，微波） 进展期HCC TACE 系统治疗（化疗） 新治疗 （分子靶向，放疗…） 早期肝癌 早期HCC的手术切除 根治？ 根治术后5年生存率：50-70％ 术后5年复发率： 60-80％ 问题：如何达到根治？如何降低复发？ Pre-operative TACE + Resection Downstaging resection：术后5年生存率 ≈小肝癌 肝动脉插管＋结扎/ TACE/ Chemotherapy？ 减小瘤体：手术简单，且控制微小病灶 减少血供：手术安全 减少术中播散 Pre-operative TACE Risk：可切除 －－ 不可切除 对肝功能差的病人：进一步损害肝功能 Japan：RCT 结果类似（Sasaki A. Eur J Surg Oncol. 2006;32:773–9.） 肝移植 术后复发 （周俭教授） 肝源等待：Bridge Treatments of Hepatocellular Carcinoma in Cirrhotic Patients Submitted to Liver Transplantation. Dig Dis Sci (2008) 53:2830–2831 TACE: Bridge to OLT Does not improve long-term survival (grade C). No convincing evidence that TACE allows to expand the current selection criteria for OLT, nor that TACE decreases dropout rates on the waiting list (grade C). TACE does not increase the risk for postoperative complications (grade C). There is insufficient evidence that TACE offers any benefit when used prior to OLT, neither for early nor for advanced HCC. 局部毁损 小肝癌：媲美于手术切除 复发率值得担心 PEI or RFA? PEI 3y 5y Child A (survival 3 vs. 5y.) 79% 47% Child B (survival 3 vs. 5y.) 63% 29% Child C (survival 3 vs. 5y.) 12% 0% RF vs PEI Local ablative therapies in HCC: percutaneous ethanol injection and radiofrequency ablation RFA is superior to PEI for treating small HCC survival after PEI or RFA in comparison with surgery TACE+ PEI/RFA survival was improved further. RF+PEI 操作性的 RF vs Resection Puzzle Pre-TACE +Resection no use Pre-TACE + RF improved RF = Resection Radical resection ＋ IFN-a resection + IFN resection OS: 63.8 months 38.8 months P=0.0003 DFS: 31.2 months 17.7 months P=0.142 Post adjuvant TACE Post adjuvant TACE 进展期肝癌 TACE Chemotherapy Chemo-immunotherapy Radiotherapy Conclusion There is lack of effective treatment for patients wi