64肝癌细胞癌管理英文原文 最新资料 (英文PDF,本空间提供对应中文下载下载)

AASLDPRACTICEGUIDELINEManagementofHepatocellularCarcinoma:AnUpdateJordiBruix1andMorrisSherman2PreambleTherecommendationsprovidedinthisdocumentpro-videadata-supportedapproachtothediagnosis,stagingandtreatmentofpatientsdiagnosedwithhepatocellularcarcinoma(HCC).Theyarebasedonthefollowing:(a)formalreviewandanalysisoftherecently-publishedworldliteratureonthetopic(Medlinesearchthroughearly2010);(b)AmericanCollegeofPhysiciansManualforAssessingHealthPracticesandDesigningPracticeGuidelines1;(c)guidelinepolicies,includingtheAASLDPolicyontheDevelopmentandUseofPracticeGuidelinesandtheAmericanGastroenterologyAssocia-tionPolicyStatementonGuidelines2;(d)theexperienceoftheauthors.Theserecommendationssuggestpre-ferredapproachestothediagnostic,therapeutic,andpreventiveaspectsofcare.Inanattempttocharacterizethequalityofevidencesupportingrecommendations,thePracticeGuidelinesCommitteeoftheAmericanAssociationforStudyofLiverDisease(AASLD)requiresacategorytobeassignedandreportedwitheachrecommendation(Table1).Theserecommenda-tionsarefullyendorsedbytheAmericanAssociationfortheStudyofLiverDiseases.IntroductionTheincidenceofhepatocellularcarcinomaisrisinginmanycountries,3-8,butinafewareassuchasJapanandSingapore,theincidenceofHCCseemstohavestabilizedorevenfallenslightly.9,10CareofthepatientwithHCCinvolvesphysiciansfromdifferentdisci-plines,includinghepatologists,surgeons,livertrans-plantteams,oncologists,interventionalradiologists,andtosomeextentradiationoncologists.Inmostset-tings,theroleofthehepatologistorgastroenterologistinthesemulti-specialtygroups(usuallyorganizedasTumorBoards)isnotbasedonspecificexpertiseintheapplicationofagivenintervention,butratherinassessingthedegreeofliverfunctionimpairmentpriorto,duringandaftertherapy.ThisspecificexpertiseisimportantsinceHCCusuallyappearsinthesettingofunderlyingliverdisease.Thisresultsinadegreeofcomplexitythatisnotpresentinothercancertypesthatseldomcompromisevitalorganfunction.AllthissuggeststhatpatientswithHCCshouldbemanagedinmultidisciplinarysettings,withalllegitimatetreat-mentoptionsavailable.Underthesecircumstances,thehepatologististobeafocalpointaroundwhomtheprocessrevolves.Atalltimes,thehepatologistshouldassessliverfunctionandsuitabilityofvarioustherapies.Thehepatologistshouldalsoberesponsibleforman-agementoftheliverdiseasebefore,during,andaftercancertherapy.He/shemustensurethatonlytreat-mentsofprovenvalueareadministered,ratherthantreatmentsthataretechnicallyfeasiblebutwhichhavenotbeenshowntoenhancesurvival.SurveillanceforHepatocellularCarcinomaDefinitionsofthetermsusedinthissectionaregiveninTable2.SurveillanceforHCCinvolvesmorethansimplyapplyingascreeningtestortests.Surveil-lanceshouldbeofferedinthesettingofaprogramoraprocessinwhichscreeningtestsandrecallprocedureshavebeenstandardizedandinwhichqualitycontrolproceduresareinplace.TheprocessofsurveillancealsoinvolvesdecidingwhatlevelofriskofHCCishighenoughtotriggersurveillance,whatscreeningteststoapplyandhowfrequently(surveillanceinter-val),andhowabnormalresultsshouldbedealtwith(diagnosisand/orrecall).SurveillanceforHCChasbecomewidelyapplieddespite,untilrecently,theabsenceofevidenceofbene-fit.Thereisnowasinglerandomizedcontrolledtrialofsurveillanceversusnosurveillancethathasshownasurvivalbenefittoastrategyof6-monthlysurveillancewithalphafetoprotein(AFP)andultrasound.11Thisstudy,whichwasperformedinChina,recruited18,816patientswhohadmarkersofcurrentorpriorhepatitisBinfection.Adherencetosurveillancewassuboptimal(lessthan60%)butinthesubjectsintheFromthe1BCLCGroup.LiverUnit.HospitalClı´nic,UniversityofBarcelona,Institutd’InvestigacionsBiome’diquesAugustPiiSunyer,Barcelona,Spain;2UniversityofTorontoandUniversityHealthNetwork,TorontoCanada.Bothauthorscontributedequallytothiswork.CopyrightVC2010bytheAmericanAssociationfortheStudyofLiverDiseasesandpublishedonlineat().Potentialconflictofinterest:JordiBruixhasreceivedresearchsupportandconsultingandlecturefeesfromBayer;andMorrisShermanhasreceivedlecturefeesfromBayer.1surveillancearmtheHCCrelatedmortalitywasreducedby37%.Becauseofpoorcompliancetheseresultsprobablyrepresenttheminimumbenefitthatcanbeexpectedfromsurveillance.Ideally,theseresultsshouldbevalidatedinothergeographicalareasandtherefore,additionalrandomizedcontrolledtrials(RCT)assessingthebenefitsofsurveillancearestillconsiderednecessary.However,intheWestitisunlikelythatsuchtrialswilleverbeconducted.TheobjectiveofHCCsurveillancemustbetodecreasemortalityfromthedisease.FewerpeopleshoulddiefromHCC,orifthisisnotpossible,sur-veillanceshouldataminimumprovideameaningfulimprovementinsurvivalduration.Otherendpoints,suchasstagemigration(detectingearlierstagedisease)and5-yearmortalityratesarenotappropriatesurro-gateendpoints.Thishasclearlybeenshownbyanaly-sisoftheSurveillance,EpidemiologyandEndResults(SEER)ProgramoftheNationalCancerInstitute(NCI),whichdemonstratedthattheseendpointsdidnotcorrelatewithareductionindisease-specificmortality.12Th