肝細胞癌診治的新進展

Recent Advances in the Management of Hepatocellular Carcinoma

林錫銘(Shi-Ming Lin)

《內科學誌》 23卷6期 (2012/12) Pp. 398-402

https://doi.org/10.6314/JIMT.2012.23(6).04

摘要

肝癌是常見的癌症，診斷上只要在肝硬化下，CT或MRI呈現肝癌的典型血管特徵即可；若是CT或MRI診斷有困難，可使用對比劑顯影超音波，特別是長時間滯留肝臟的Sonazoid，更有助於診斷；也可使用肝細胞特異性對比劑Primovist-MRI，在肝細胞膽道相更能呈現影像強度降低，也有助於診斷小肝癌。治療方面，小型可切除的肝癌仍以手術切除為主，對於肝功能不佳甚至失代償或肝癌復發者，如果肝癌仍在米蘭或舊金山大學規約者，建議肝移植治療；小型肝癌若不適合切除者，可以使用局部消融治療，特別是以自動射頻轉換器加上多支射頻探針來治療3公分以上的肝癌，腫瘤的完全消融率可達90%以上。對於超音波下不易辨認的肝腫瘤，可使用虛擬超音波，有助於準確的治療。對於中晚期肝癌，若是傳統的肝動脈栓塞療效不佳或副作用較大時，可使用DC Bead或Hepa-sphere微球載藥，經導管注入肝動脈後，可提高腫瘤內化療藥物濃度，降低全身性副作用。另外將釔90微球經由肝動脈注入肝臟內，可藉由緩慢釋放的輻射線將肝癌大範圍的殺死。對於肝功能尚佳且已侵犯肝臟大靜脈或已肝外轉移者，標靶治療（蕾莎瓦）可以單獨使用或合併肝動脈化學栓塞，若能即早治療其副作用，則接受蕾莎瓦的時間較長療效也會較佳，亦可以延長存活。

關鍵字

對比劑顯影超音波 ； Primovist磁振造影 ； 自動射頻轉換器 ； 微球載藥動脈栓塞 ； 釔90放射栓塞 ； 標靶治療

並列摘要

Recent advances in the diagnosis and treatment have improved the outcome of HCC. The diagnosis of HCC can be made with the typical hypervascular findings of HCC on CT or MRI. If not, it can be further made by contrast-enhanced ultrasonography, particularly the application of Sonazoid with Kupffer-phase hypoechoic finding. Primovist-MRI can further show hypodense imaging on the hepato-biliary phase and thus more useful in the diagnosis of small HCC without hypodense finding on venous or delayed phase on CT or SPIO-MRI. In the treatment of HCC, resection remains the choice for resectable HCC. In case with hepatic decompensation or recurrence of HCC and within the Milan or UCSF criteria, liver transplantation is the option of treatment. For un-resectable small HCC, local ablation is another choice for curative treatment. Among the local ablative modalities, switching RF controller with multiple radiofrequency (RF) electrodes has improved the rate of complete above 90% in medium or large HCC. In case HCC nodules sometimes cannot be shown in the cirrhotic background under ultrasonography, it can be overcome by using combination of CT or MRI navigation and real-time virtual sonography. Conventional TACE remains the standard treatment for intermediate or advanced stage HCC with preserved liver reserve and without vascular invasion. In case with severe adverse effects or poor response after conventional TACE, drug-eluting beads by using DC-bead or Hepa-sphere bead can enhance the anti-tumoral effects and reduce severe adverse effects. Yittrium-90 radioembolization with prolonged internal radiation can effectively ablate the cancers cells. For HCC with major vascular invasion or extra-hepatic spreading, sorafenib can prolong the survival, particularly in the patents with longer administration period once the adverse effects can be early detected, prevented or controlled.

並列關鍵字

Contrast-enhanced ultrasonography ； Primovist-MRI ； Switching RF controller ； Drug-eluting micro-bead embolization ； Yttrium-90 radioembolization ； Target therapy