摘要
TNM (tumor-node-metastasis) staging system is used to describe stages in most of cancers. Besides of cancer death itself, near half of patients with hepatocellular carcinoma (HCC), or hepatoma, died of hepatic failure. Therefore, tumor status as well as liver function reserve are two key prognostic factors of HCC. When staging tumor status, all items including tumor size, tumor number, vascular involvement, direct invasion to nearby organs, local lymph node and distant metastasis, should be considered as TNM systems. The major difference between clinical and pathological staging is macro-or microscopic vascular invasion. For low resection rate of HCC, clinical staging should be more practical than pathological staging. The prognoses of cases with ”Single tumor ＜2cm” were the best and those with ”tumor with vascular invasion” should be the worst. These two groups must be identified in the staging systems. Child-Pugh's Classification, including albumin, bilirubin, prothrombin time, ascites and encephalopathy, is the common scoring system of liver function reserve. Japanese integrated score (JIS) is the sum of TNM score and Child's score. In JIS, a simplified TNM (LCSJG, Liver Cancer Study Group Japan) are used instead of AJCC TNM. Only 3 factors are considered in TNM LCSGJ, i.e. single tumor, diameter ＜2cm and without vascular invasion. If cases meet all 3 factors are staged as T1, 2 factors as T2, 1 as T3 and 0 as T4. In 1985, Okuda reported the 1(superscript st) stageing system of HCC considering both liver functional reserve and tumor status. Okuda staging system included 4 poor prognosis factors, i.e. tumor ＞50% total liver volume, ascites, albumin ＜3g/L and bilirubin ＞3 mg/dl. Patients without any poor prognostic factor were groups as stage1, with one or two factors were stage 2, and with three or four factors were stage 3. In 1998, CLIP (Cancer of the Liver Italian Program) score was published. It is sum of 4 items. The items were graded as tumor (0:＜50% total liver volume, single; 1:＜50% total liver volume, multiple; 2:＞50% total liver volume), Child's classification (0: A; 1: B; 2: C), AFP ＞400ng/ml (0: no; 1: yes) and macro vascular invasion (0: no; 1: yes). The discriminability of CLIP score is better than the Okuda staging. Improving ultrasonographic diagnosis of tumor and vascular invasion and including AFP were the reasons of improvement. HCC staging systems were not only for prognosis prediction but also for treatment assignment. The HCC practice guideline of AASLD (American Association for the Study of Liver Disease) recommends treatment modalities according to BCLC (Barcelona Clinic Liver Cancer) stageing system. Based on liver function reserve by Child's classification, tumor status similar to TNM and WHO performance status, BCLC stages HCC patients into very early, early, intermediate, advanced and terminal stages. Curative treatment, such as transplantation, surgical resection and tumor ablation by percutenous ethanol injection (PEI) and radiofrequency ablation (RFA) were choices of patients of very early and early stages. Transcatheter arterial chemoembolization (TACE) is recommended for cases of intermediate stage. New agents under randomized control trial might be choice of advanced patients. Terminal patients should undergo only conservative treatment. AASLD practice guideline is acceptable in Taiwan. However, the clinical practice in Taiwan is similar to Japanese guideline than Americans. In recent years, higher coverage rates of HCC surveillance on high risk subjects, anti-viral treatment of chronic hepatitis reimbursed by the National Health Insurance, improvement of instrument and technique of RFA, and some other reasons, the survival of HCC patients is prolonging. HCC staging system will be revising by the changes.
並列摘要
TNM (tumor-node-metastasis) staging system is used to describe stages in most of cancers. Besides of cancer death itself, near half of patients with hepatocellular carcinoma (HCC), or hepatoma, died of hepatic failure. Therefore, tumor status as well as liver function reserve are two key prognostic factors of HCC. When staging tumor status, all items including tumor size, tumor number, vascular involvement, direct invasion to nearby organs, local lymph node and distant metastasis, should be considered as TNM systems. The major difference between clinical and pathological staging is macro-or microscopic vascular invasion. For low resection rate of HCC, clinical staging should be more practical than pathological staging. The prognoses of cases with ”Single tumor ＜2cm” were the best and those with ”tumor with vascular invasion” should be the worst. These two groups must be identified in the staging systems. Child-Pugh's Classification, including albumin, bilirubin, prothrombin time, ascites and encephalopathy, is the common scoring system of liver function reserve. Japanese integrated score (JIS) is the sum of TNM score and Child's score. In JIS, a simplified TNM (LCSJG, Liver Cancer Study Group Japan) are used instead of AJCC TNM. Only 3 factors are considered in TNM LCSGJ, i.e. single tumor, diameter ＜2cm and without vascular invasion. If cases meet all 3 factors are staged as T1, 2 factors as T2, 1 as T3 and 0 as T4. In 1985, Okuda reported the 1(superscript st) stageing system of HCC considering both liver functional reserve and tumor status. Okuda staging system included 4 poor prognosis factors, i.e. tumor ＞50% total liver volume, ascites, albumin ＜3g/L and bilirubin ＞3 mg/dl. Patients without any poor prognostic factor were groups as stage1, with one or two factors were stage 2, and with three or four factors were stage 3. In 1998, CLIP (Cancer of the Liver Italian Program) score was published. It is sum of 4 items. The items were graded as tumor (0:＜50% total liver volume, single; 1:＜50% total liver volume, multiple; 2:＞50% total liver volume), Child's classification (0: A; 1: B; 2: C), AFP ＞400ng/ml (0: no; 1: yes) and macro vascular invasion (0: no; 1: yes). The discriminability of CLIP score is better than the Okuda staging. Improving ultrasonographic diagnosis of tumor and vascular invasion and including AFP were the reasons of improvement. HCC staging systems were not only for prognosis prediction but also for treatment assignment. The HCC practice guideline of AASLD (American Association for the Study of Liver Disease) recommends treatment modalities according to BCLC (Barcelona Clinic Liver Cancer) stageing system. Based on liver function reserve by Child's classification, tumor status similar to TNM and WHO performance status, BCLC stages HCC patients into very early, early, intermediate, advanced and terminal stages. Curative treatment, such as transplantation, surgical resection and tumor ablation by percutenous ethanol injection (PEI) and radiofrequency ablation (RFA) were choices of patients of very early and early stages. Transcatheter arterial chemoembolization (TACE) is recommended for cases of intermediate stage. New agents under randomized control trial might be choice of advanced patients. Terminal patients should undergo only conservative treatment. AASLD practice guideline is acceptable in Taiwan. However, the clinical practice in Taiwan is similar to Japanese guideline than Americans. In recent years, higher coverage rates of HCC surveillance on high risk subjects, anti-viral treatment of chronic hepatitis reimbursed by the National Health Insurance, improvement of instrument and technique of RFA, and some other reasons, the survival of HCC patients is prolonging. HCC staging system will be revising by the changes.
被引用紀錄
延伸閱讀
- 張文宇（1989）。肝細胞癌的診斷與預後。中華民國消化系醫學會雜誌，6(1)，50-50。https://www.airitilibrary.com/Article/Detail?DocID=a0000204-198903-6-1-50-50-a
- 胡志棠（2001）。肝細胞癌－臨床篇。當代醫學，(334)，666-673。https://doi.org/10.29941/MT.200108.0016
- 魏裕峰、高嘉宏（2004）。肝細胞癌之分期與治療。當代醫學，(370)，646-653。https://doi.org/10.29941/MT.200408.0011
- 張可斌、李重賓（2019）。肝細胞癌的標靶治療。臨床醫學月刊，83(4)，239-245。https://doi.org/10.6666/ClinMed.201904_83(4).0039
- 林志陵、高嘉宏（2008）。Epidemiology of Hepatocellular Carcinoma。中華民國癌症醫學會雜誌，24(5)，277-281。https://doi.org/10.6588/JCOS.2008.24.5.1