原发性肝癌英文版培训课件.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,原发性肝癌英文版,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,原发性肝癌英文版,*,原发性肝癌英文版,The normal liver,The largest organ inside the body,Located just below the ribs on the right side,Liver cells are called hepatocytes,Has many functions,(filter,produces enzymes and bile),2,原发性肝癌英文版,Numbers about HCC,Number 5 in the world,Number 3 among cancer mortality,5 year survival rate is approximately 6.9%,About 50%of the worlds cases occur in China,The king of cancer,3,原发性肝癌英文版,Global Incidence of HCC Distribution,4,原发性肝癌英文版,Definition,A primary malignancy of hepatocellular origin,CT image,HCC,5,原发性肝癌英文版,Risk factors,Hepatitis B,：,an infectious disease caused by hepatitis B virus(HBV),Hepatitis C,HBV,HCV,6,原发性肝癌英文版,Evidence of association between HBV and HCC,Prevention of HBV reduces risk of subsequent HCC,HBV carriers have shown very high relative risks for HCC,HBV sequences are present in HCC tissues,High mortality rates for HCC also have high HBV infection rates,7,原发性肝癌英文版,Global Incidence of Hepatitis B Distribution,8,原发性肝癌英文版,Risk factors,Cirrhosis of the liver(,肝硬化,),A consequence of chronic liver disease characterized by replacement of liver tissue by fibrosis(,纤维化,),scar tissue and regenerative nodules(,再生结节,).,Which one is normal?,9,原发性肝癌英文版,Basic Mechanism of Liver Fibrosis,Alcohol,Hepatitis Virus,Congenital Disorders,Cholestasis,Nonalcoholic Steatohepatitis,Chronic Damage,to Liver Cells,Release of Proinflammatory,Mediators,Chronic Release,of Mediators that,Stimulate Repair,Chronic,Inflammation,Activation of,Myofibroblasts,Production of,Extracellular,Matrix,Liver Fibrosis,肌纤维母细胞,细胞外基质,10,原发性肝癌英文版,Aflatoxin(,黄曲霉素,),Toxic and carcinogenic substances,Metabolized by the liver,Risk factors,Peanut,11,原发性肝癌英文版,Risk factors,Water pollution,：,blue-green algae,blue-green algae(,蓝绿藻）,12,原发性肝癌英文版,Alcohol,Nonalcoholic Fatty Liver Disease,Type 2 Diabetes,Obesity,Gender,Risk factors,GASTROENTEROLOGY 2004;127,GASTROENTEROLOGY 2007;132:25572576,13,原发性肝癌英文版,The development of hepatocellular carcinoma in human,14,原发性肝癌英文版,Pathology(,病理,),Three morphologic types,Block type,（块状型）,Diameter 5,associated with cirrhosis,Nodular type,（结节型）,Diameter,500ng/ml for 4 weeks,200ng/ml for 8 weeks,AFP over time,2.,Monitor a patients response to therapy and for cancer,recurrence,Blood tests of liver function,Blood tests for Hepatitis B and C,36,原发性肝癌英文版,Ultrasound test,Tumors may produce different echoes,37,原发性肝癌英文版,A procedure that makes a series of detailed pictures,CT:Venous Phase,CT:Arterial Phase,CT scan,38,原发性肝癌英文版,Magnetic resonance imaging(MRI),39,原发性肝癌英文版,Liver biopsy,40,原发性肝癌英文版,一、肝癌标记物,甲胎蛋白（,AFP,）,1.,临床意义：,诊断原发性肝癌特异性强，阳性率,70-90%,，假阳性极少；,早期诊断肝癌，先于症状,8-11,月；,适用于普查、诊断、判断疗效、预测复发,临床检查,41,原发性肝癌英文版,甲胎蛋白（,AFP,）,2.,诊断标准：,AFP500g/l,，持续,4,周,AFP,由低浓度逐渐升高不降,AFP200g/l,，持续,8,周,3,假阳性：妊娠、生殖腺胚胎瘤、肝病活动期,4,假阴性：与肿瘤分化程度、病理 变 化、检测方法有关,临床检查,42,原发性肝癌英文版,其它肝癌标记物,1,、,-GT-2,同功酶,2,、,APT,（异常凝血酶原）,3,、,血清岩藻糖苷酶（,AFu,）,4,、,其他,临床检查,价值有限，临床少开展,43,原发性肝癌英文版,二、影像学检查,1,、,B,超,（,筛查,首选，,d=2cm,，彩超可提高阳性率）,2,、,CT,（诊断、术前常规检查）,3,、,MRI,（多断面，血管结构清晰，非放射）,4,、肝血管造影,（有创，未能定性定位者，行动脉栓塞治疗者）,影像学进展,：高清晰度,CT,，超声造影，,PET-CT,三、肝穿刺活检,临床检查,44,原发性肝癌英文版,How is liver cancer diagnosed?,Medical history,Physical exam,If a patient has symptoms that suggest liver cancer,Blood tests,Image US,CT,MRI,Biopsy may not be required,Workup,45,原发性肝癌英文版,46,原发性肝癌英文版,A 55-year-old man was admitted to hospital:,Due to numbness and weakness on his right side,His initial laboratory examination:AST:160 U/L,ALT 88 U/L,GGT 55 U/L,alkaline phosphatase 288 mg/Dl,The patients medical history was significant for chronic HBV-related hepatitis,What should doctors do with this patient?,AFP 400 U/L,CT scan,Needle biopsy-Pathological examination,Case 1:hepatocellular carcinoma,World J Gastroenterol 2004;10(11):1688-1689,47,原发性肝癌英文版,高危人群的普查：,1,、,有乙、丙肝炎病毒感染史,2,、,35,岁（特别是男性）,3,、,慢性活动性肝炎,4,、,各种病因所致的肝硬化,5,、报警征像：肝区疼痛、进行性肝大、贫血、消瘦,普查措施：,AFP,、,B,超（,随诊,）,诊断,48,原发性肝癌英文版,一、非侵入性诊断标准,1,、影像学（,两种,影像学均显示,2cm,的肝癌特征性占位病灶,）,2,、,影像学结合,AFP,（一种影像学检查,+AFP,400,ug/L,排除妊娠、生殖性肿瘤、继发性肝癌等,）,二、侵入性诊断标准,影像学不能确诊的,2cm,的肝内结节,肝穿刺活检,诊断,49,原发性肝癌英文版,1,、,继发性肝癌,（原发癌表现，,AFP,一般不高）,2,、,肝硬化,（难点，,随访,）,3,、,病毒性肝病,（,AFP,和,ALT,动态,曲线分离,）,4,、,肝脓肿,（发热、,WBC,高、影像学）,5,、,肝局部脂肪浸润,（增强,CT,）,6,、,肝外邻近器官肿瘤,（影像学，,AFP,）,7,、,肝内非癌性占位病变,（影像学，肝穿）,8,、其它,AFP,升高的非肝癌病变,（生殖性肿瘤）,鉴别诊断,50,原发性肝癌英文版,51,原发性肝癌英文版,肝癌治疗方法,外科：肿瘤切除、姑息性手术（肝,A,结扎、,插管、门,V,插管、冷冻、热凝）、肝移植,经导管介入：肝,A,化疗栓塞（,TACE）、,门,V,化疗栓塞,经皮局部毁除术：瘤内注射、瘤内加热（射频、激光、微波、高强聚焦超声）、冷冻（氦氩）,化疗,放射,免疫、导向、中医,52,原发性肝癌英文版,肿瘤靠近大血管,PV.R,LIMITATION of HEPATECTOMY,53,原发性肝癌英文版,Treatments,Surgery,The only proven potentially curative therapy for HCC(Hepatic resection or liver transplantation),Chemotherapy and radiation treatments are not,usually effective,54,原发性肝癌英文版,肝癌序贯治疗选择,肝癌,期,期,期,外科切除,外科姑息手术（不能切除者）,导管介入(,TACE),(,癌肿范围大者),经皮毁除术(,PEI,PRFE,HIFU),(,癌肿范围小者),晚期,追踪,外科切除,化疗,免疫治疗,中药,核素照射,55,原发性肝癌英文版,高强超声聚焦疗法(,High intensity focused ultrasound,HIFU),原理：利用超声瞬间高温能量聚集,适应症：肝癌、乳腺癌、骨肿瘤、软组,织肿瘤、肾癌等实体肿瘤,优点：无创（不需穿刺），,B,超监视下适,形实时毁除，可治分散病灶,缺点：设备要求高，手术时间长，全麻,56,原发性肝癌英文版,高强超声聚焦刀（HIFU）,57,原发性肝癌英文版,HIFU,治疗原理,焦域,组织,探头示意图,58,原发性肝癌英文版,HIFU,治疗前,HIFU,治疗后5个月,Contrast-Enhanced MRI,T1W,原发性肝癌,HIFU,治疗前后,MR,表现,59,原发性肝癌英文版,多极射频肿瘤消融术,原理：高频震荡电流经过射频消融电极，,使电极周围离子发生震荡，离子相互,碰撞产生热量，使周围组织温度达到,80100，局部肿瘤组织因此发生凝,固性坏死甚至炭化。,适应症：肝癌、肺癌、肾癌、脾脏及,肾上腺肿瘤等,60,原发性肝癌英文版,多极射频肿瘤消融仪,61,原发性肝癌英文版,射频肿瘤消融电极（多极）,62,原发性肝癌英文版,原发性肝癌射频消融术,63,原发性肝癌英文版,经导管肝动脉化疗栓塞术(TACE)原理,肝血液供应：正常 肝,A 25%、,门,V 75%,肝癌 肝,A 90%、,门,V 10%,肝,A,栓塞癌区供血减90%，正常区30-40%,肿瘤内血管迂曲，缺,N,支配，通透性高，碘油、带药微球易滞留,65,原发性肝癌英文版,TACE疗效和适应征,短期疗效：75%癌块缩小，90%AFP下降,远期疗效：复发率高，需联用其他疗法,适应症：不能手术的中晚期肝癌,66,原发性肝癌英文版,介入治疗前肝脏,CT,示肝右叶后下段结节型肝癌,微导管肝右后叶下亚段(,段)动脉高超选择性插管造影，显示富血管型肿瘤病灶,肝癌,TACE,治疗-病例1,67,原发性肝癌英文版,经门V栓塞化疗,经脐V或经皮穿刺插管，操作复杂,单用疗效不好，需和TACE联用,68,原发性肝癌英文版,经皮乙醇注射（PEI）,方法：超声（其他影像）指导下单点、,连锁注射,优点：简便、有效，便于基层推广，,有效率60-80%,缺点：并发症（术后疼痛、发热、乙醇,中毒，罕有出血、气胸、感染等）,适应症：多数，失去手术机会；多数，,小肝癌（和手术疗效相近？）,69,原发性肝癌英文版,经皮穿刺冷冻疗法氩氦刀,原理：导针穿刺癌瘤，接氩氦冷冻系统,输氩气-140 靶组织冰球,输氦气 25-40 复温,优点：和经皮热凝固疗效相似，较安全,缺点：穿刺并发症,70,原发性肝癌英文版,原则：早期诊断、手术根除,不能切除者采取综合治疗,个体化,治疗,71,原发性肝癌英文版,多学科融合的序贯治疗,外科,化疗,放疗,生物治疗,介入治疗,中医治疗,肝癌,治疗,72,原发性肝癌英文版,一、手术治疗,适应症：,1,、诊断明确，病变局限于一叶或半肝者，未侵及肝门及下腔静脉者；,2,、肝功能代偿良好，,PT,不能低于正常,50%,；,3,、无明显黄疸、腹水或远处转移者、慢性活动性肝炎,4,、心、肺、肾功能良好，能耐受手术者,5,、术后复发，病变局限于肝的一侧者；,6,、经其它治疗，病灶明显缩小，估计能手术切除者。,治疗,73,原发性肝癌英文版,病案,男性，,40,岁，肝区疼痛半月余，伴有乏力、纳差、消瘦。,PE,：巩膜黄染，肝肋下,6cm,，剑突下,4cm,，质硬，表面不平，有大小不等的结节，缘钝，压痛。脾肋下,3cm,，移动性浊音（,+,）,初步诊断？下一步处理？,74,原发性肝癌英文版,初步诊断,鉴别诊断,进一步检查,治疗原则,执业医师考试 肝癌病例分析,75,原发性肝癌英文版,局部与全身并重的原则,分期治疗的原则,个体化治疗的原则,生存率与生活质量并重的原则,成本与效果并重的原则,中西医并重的原则,治疗规范化,76,原发性肝癌英文版,预后好的因素：,瘤体小于,5cm,，能早期手术；,癌肿包膜完整，无癌栓；,机体免疫状态良好；,预后差：,合并肝硬化、远处转移、发生肝癌破裂、消化道出血等并发症,预后,77,原发性肝癌英文版,78,原发性肝癌英文版,