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3、界每年,38.6,万死于肝癌,我国每年发病率,20.40/10,万,19.98/10,万,(,城市）,23.59/10,万（农村）,全,国每年肝癌死亡率为,20.40,10,万,死亡率居肿瘤死亡率第二位,手术切除率仅为,200%,2,原发性肝癌诊治进展,病毒性肝炎及肝炎后肝硬化,黄曲霉毒素,饮水污染及化学致癌物,代谢紊乱有关,病 因 学,3,原发性肝癌诊治进展,hbv,hcv,alcohol,metabolic disorders,chronic injury inflammation,regeneration,genetic/epigenetic alterations,hcc,envi
4、ronmential,factors(afb1),growth factor activation,发病机制,4,原发性肝癌诊治进展,hepatitis,cirrhosis,hcc,15-20�velop cirrhosis in 5 years,liaw et al.hepatology 1988,fattovich et al gut 1991,risk of hcc increased by 200 folds,beasley et al.lancet 1981,liaw et al.liver 1989,5-year survival 55%,40%of asian men wit
5、h chb die of complications,weissberg et al.ann intern med 1984,beasley lancet 1981,乙肝病程,5,原发性肝癌诊治进展,我国肝癌患者中有乙型肝炎病毒感染的约占,90%,我国,hbv,的携带率约为,10%,，欧美为,1%,每年还有,100,万新生儿在围产期获得,hbv,感染,五年内,15%,乙型肝炎发生肝硬化,肝硬化发生原发性肝癌的概率为,9.9.6%,乙肝流行病学,6,原发性肝癌诊治进展,european association for the study of the liver(easl)surveill
6、ance and recall strategy for hcc,原发性肝癌诊断流程,7,原发性肝癌诊治进展,原发性肝癌超声造影检查,8,原发性肝癌诊治进展,原发性肝癌,ct,三期成像,1,2,3,1：,平扫,2：,动脉期,3：,门脉后期,9,原发性肝癌诊治进展,triphase liver protocol,原发性肝癌诊断流程,10,原发性肝癌诊治进展,t1wi,、,varied t2wi,原发性肝癌诊断流程,11,原发性肝癌诊治进展,简单分期,ajcc/uicc,分期,clip（cancer of the liver italian program）,分期,okuda,分期,bclc（ba
7、rcelona clinic liver cancer）,分期,原发性肝癌分期,12,原发性肝癌诊治进展,期：（亚临床期）无明显症状和 体征。,期：出现临床症状或体征但无,期表现,期：有黄疸、腹水、远处转移或 恶液质之一者。,原发性肝癌简单分期,13,原发性肝癌诊治进展,primary tumor(t),tx,primary tumor cannot be assessed,t0,no evidence of primary tumor,t1,solitary tumor without vascular invasion,t2,solitary tumor with vascular inv
8、asion or,multiple tumors none more than 5 cm,t3,multiple tumors more than 5 cm or,tumor involving a major branch of the portal or,hepatic vein(s),t4,tumor(s)with direct invasion of adjacent organs,other than the gallbladder or,with perforation of visceral peritoneum,ajcc/uicc,分期,14,原发性肝癌诊治进展,regiona
9、l lymph nodes(n),nx,regional lymph nodes cannot be assessed,n0,no regional lymph node metastasis,n1,regional lymph node metastasis,distant metastasis(m),mx,distant metastasis cannot be assessed,m0,no distant metastasis,m1,distant metastasis,ajcc/uicc,分期,15,原发性肝癌诊治进展,stage grouping,stage i,t1,n0,m0,s
10、tage ii,t2,n0,m0,stage iiia,t3,n0,m0,stage iiib,t4,n0,m0,stage iiic,any t,n1,m0,stage iv,any t,any n,m1,ajcc/uicc,分期,16,原发性肝癌诊治进展,clip,分期,17,原发性肝癌诊治进展,okuda,分期,18,原发性肝癌诊治进展,50,60,年代肝脏外科解剖学基础上的极量切除,70,80,年代局部根治性切除理论,80,90,年代以手术治疗为主的综合治疗观念,我国肝癌诊治的三个发展时期,19,原发性肝癌诊治进展,手术治疗方法,-,肝切除术，肝移植术,微创治疗,tace,、,pei,
11、、,rfa,非手术治疗方法,-,放疗 内放射（,131i,90y),立体定向,-,化疗,-,分子靶向治疗,原发性肝癌治疗现状,20,原发性肝癌诊治进展,bcla,原发性肝癌诊治流程,21,原发性肝癌诊治进展,患者全身状况,肿瘤部位、大小、数量,门静脉、肝静脉及胆管侵犯,肝内及肝外转移,肝硬化程度及肝功能代偿状况,肝癌切除前评估,22,原发性肝癌诊治进展,icg r15,pugh-childs classification,ct volumetric study,肝功能评估,23,原发性肝癌诊治进展,child-turcotte-pugh(ctp)classification,variable,
12、1,2,3,encephalopathy grade,none,1-2,3-4,acites,absent,slight,morderate,albumin(g/dl),3.5,2.8-3.5,2.8,pt(sec prolonged),6,bilirubin(mg/dl),3,for cholestatic disease,10,a:5-6,b:7-9,c:10-15,24,原发性肝癌诊治进展,解剖第一肝门,25,原发性肝癌诊治进展,解剖第二肝门,26,原发性肝癌诊治进展,解剖第三肝门,27,原发性肝癌诊治进展,viii segment tumor,case-1,28,原发性肝癌诊治进展,c
13、usa resection protect mhv,29,原发性肝癌诊治进展,vi,vii,viii segment tumor,case-2,30,原发性肝癌诊治进展,cusa resection plane,31,原发性肝癌诊治进展,32,原发性肝癌诊治进展,33,原发性肝癌诊治进展,case-4,34,原发性肝癌诊治进展,35,原发性肝癌诊治进展,36,原发性肝癌诊治进展,case-5,37,原发性肝癌诊治进展,38,原发性肝癌诊治进展,author,country,year,survival rate,（,%,）,n,1y,3y,5y,nagao,japan,1987,98,73,42
14、,25,chen,taiwan,1997,382,71,52,46,lee,taiwan,1998,245,86,62,49,belghiti,french,2002,300,81,57,37,ercolani,italy,2003,224,83,63,43,lai,hk,1995,343,68,45,35,takenaka,japan,1996,280,88,70,50,poon,hk,2001,241,82,62,49,zhou,china,2001,2366,82.6,61,49.7,wu,china,2005,6446,85.9,64.6,53.2,肝癌手术治疗效果,39,原发性肝癌诊
15、治进展,author,n,recurrence rates(%),1,3,5,xd zhou,308,9.2,38.8,54.1,imamura h,249,30.1,62.3,79.0,wakai t,111,28,49,62.0,f shen,823,30.3,58.8,66.5,肝癌术后复发率,40,原发性肝癌诊治进展,肝癌,2cm,，单发，无血管侵犯，采用手术切除,或,rfa,或,pei,疗效均相仿,5cm,的小肝癌，施行手术切除后,5,年生存率约为,50%,左右。,上海中山医院,周信达报道,1000,例小肝癌手术切除后,5,年、,10,年生存率分别为,65.1%,和,46.6%,。,
16、东方肝胆医,院,1960,年,-1996,年,709,例小肝癌手术切除后,5,年生存率为,79.8%,，,小肝癌切除,41,原发性肝癌诊治进展,上海中山医院周信达报道,99,例，,5,年生存率达,63.5%,上海东方肝胆医院,73,例，,5,年生存率达,61.5%,肝癌二期切除效果,43,原发性肝癌诊治进展,只要肝功能良好，技术条件具备，有手术切除可能的复发肝癌，均应争取先手术切除，术后再采用综合治疗措施。,原发性肝癌复发再切除,44,原发性肝癌诊治进展,同时解决肝癌和肝硬化。,“,意外癌”患者的肝移植后,3,年生存率可达,70%,肝癌肝移植,45,原发性肝癌诊治进展,milan,ucsf,chinese criteria,milan criteria(,1996，mazzaferro),single lesion 5cm,or 3 lesions,none 3cm,ucsf criteria,：,solitary lesions 6.5 cm,or 3 lesions,none 4.5cm,and total tumor diameter 8 cm,chinese criteria?