肝切除治療肝細胞癌

Hepatectomy for Hepatocelluar Carcinoma

周嘉揚(Gar-Yang Chau)

《中華民國癌症醫學會雜誌》 24卷5期 (2008/10) Pp. 311-317

https://doi.org/10.6588/JCOS.2008.24.5.6

摘要

肝細胞癌（簡稱肝癌）的特點包括：第一、病因多重，可能是病毒性、也可能是非病毒性；第二、診斷上常有困難，有時候跟其他的肝疾病不容易分辨，第三、生物性差異大，有些腫瘤長的慢，有的長的快；第四、肝硬化或是慢性肝炎的合併，造成治療上的困擾；第五、有許多治療方法；第六、預後因子複雜；第七、肝癌通常對化學藥物和放射治療效果不佳。
肝切除治療肝癌優點是手術本身是治癒性的治療、不需重覆治療，缺點是手術有其危險性、只適合少數的病患，而且術後腫瘤復發率還是相當高。人類第一個切肝手術是在1888年完成的。早期切肝手術是相當危險，病患可能會死於肝衰竭，死亡率可達15%以上。到了九○年代，因為各種儀器、手術技巧的改進，手術死亡率已經降到2%以下，甚至可以達到零的死亡率。肝切除治療肝癌近年來比較重要的進步包括：第一點早期診斷、早期治療；第二點肝功能精確的評估，主要是用Childs準則和ICG清除率；第三點外科技巧的技術發展，譬如包括手術前做門脈的栓塞、血行阻斷、合乎解剖學的肝切除、腹腔鏡手術肝切除、手術後給病人做輔助性的治療等。檢討肝癌的預後因子、分析復發原因，這些都是代表最近外科在肝癌治療上的進步。
肝癌預後因子方面的研究，文獻上的報告相當多。台北榮總針對肝癌病患做多變數分析，與存活有關係的預後因子包括：腫瘤血管侵襲（包括macroscopic、microscopic）、外科邊緣寬度(surgical margin)、ICG、腫瘤數目、腫瘤破裂、男性、AST值等。肝癌不同的分期法中，外科較常用為AJCC/TNM分期法，其分期因子包括：血管侵襲有無、單發或多發、腫瘤＜5cm或＞5cm，腫瘤有沒有破裂、有沒有其他器官侵襲，把病患分成四期，外科能切除的是第一、第二和第三期，第四期有肝外轉移，一般來講是不適合切除的。
如何改善切除後成績，其方法不外乎有下列幾點：第一是早期診斷、早期治療；第二影像診斷要很正確，手術前要把所有腫瘤找出來；第三手術腫瘤不要破裂、減少手術出血量等等；第四給予有效的手術後輔助性治療；第五手術後腫瘤發生復發積極的給予治療。目前肝癌切除已經是一個相當安全的手術了，展望未來，我們的研究的方向應該是從基因機轉上了解腫瘤的發生與轉移，發展出預防性的治療藥物，從而減少腫瘤切除後的復發。

關鍵字

肝癌 ； 肝切除治療 ； 手術方法 ； 治療成績 ； 預後因子

並列摘要

Due to the prevalence of hepatitis B and C virus infection, the incidence of hepatocellular carcinoma (HCC) is high in Taiwan. HCC has several main features: (1) HCC usually develops on a background of chronic inflammatory liver disease with heterogeneous etiologies, main risk factors for HCC are alcohol abuse, and chronic infection with hepatitis B or C virus; (2) HCC is sometimes difficult to accurately diagnose in early-stage disease; (3) HCC varies in biological properties; (4) The high frequency of associated cirrhosis or chronic hepatitis contributes to the difficulty of disease treatment; (5) No single method of treatment has ever been developed for universal application; (6) Many factors affect the prognosis of patients with HCC; (7) HCC is usually resistant to chemotherapy and radiotherapy.
Hepatectomy for HCC assures the highest local control and is possibly curative, but presents the following weak points: perioperative risk, a low resectability rate, and a high rate of postresectional recurrence. Hepatic resection is usually restricted to patients with adequate hepatic functional reserve. The first human resection was carried out in 1888. In recent years, many techniques have been adopted by surgeons to reduce the mortality rate after hepatectomy for HCC: precise preoperative liver function assessment, preoperative portal vein embolization, resection using intraoperative ultrasonography, and intermittent inflow occlusion during liver resection. As a result, the morbidity and mortality rates after hepatectomy for HCC have been much improved in experienced centers.
Assessment of prognosis after hepatectomy has up to now been based on retrospective analyses in centers with sufficiently long experience. Studies from Taipei Veterans General Hospital indicated that tumor vascular invasion, surgical margin, indocyanine green retention at 15 min (ICG15), tumor number, tumor rupture, male gender, AST value were significant prognostic factors. The overall outcome of patients can be significantly stratified by the pathological stage (AJCC/TNM staging) of the disease.
In general, hepatectomy is the management of first choice for HCC, especially for early tumor stages. Despite the lower operative mortality rate in recent years, the long-term prognosis after surgical resection of HCC is still unsatisfactory. Potential ways which can be applied so as to improve the surgical results include: (1) Detection and treatment of the disease in early-stage; (2) Accurate image studies; (3) To avoid tumor rupture and intraoperative blood transfusion; (4) Effective adjuvant therapy; (5) Aggressive treatment, including repeated resection, for patients with recurrent diseases. In HCC, once a malignant focus is surgically excised, the risk of developing another malignant focus remains. Future studies must concentrate on investigating genes associated with HCC pathogenesis and metastasis, and developing effective treatment strategy.

並列關鍵字

hepatocellular carcinoma ； hepatectomy ； operative techniques ； outcome ； prognostic factors