原发性肝癌诊疗规范_2011年版

##(2011)中华人民共和国卫生部(卫办医政发[2011]121号);;;:R73517:A:1009-0460(2011)10-0929-181(primarylivercancer,PLC,),,,,,,,,,(HCC)(ICC)2,,HCC90%,/0HCC2211高危人群的监测筛查,,,(alpha2fetoprotein,AFP)(US)\40\50,HBV/HCV,,6,AFPHCC,AFPHCC,AFP,2010(AASLD)AFP,HCCHBV,HCC(HCV),(RCT),HCCAFP212临床表现21211,,,10(),3~5cm,,,AFP,8,,,,,,,3~6,:(1),,,,,;,;,(2),,(3),(4),,,3715~38e,,,,,;,(5),;;(6)()(7)(paraneoplasticsyndrome),,;,21212,,,,#929#2011101610ChineseClinicalOncology,Oct.2011,Vol.16,No.10(,),(1):,,,,,;,;(2):,,,,(3):,,,(4):,,,,;,21213(1):,,,(2):,,,,,,,,;,21214(1):,,,(2)():,,,(hepatorenalsyn2drome,HRS)(functionalacuterenalfailure,FARF),,,,(hepaticencephalopathy,HE),,(3):,,,,,,,,(4):,,,213辅助检查21311(,ASTGOT)(,ALTGPT)(AKP)(LDH),(HBsAg)/0(HBsAgHBsAbHBeAgHBeAbHBcAb)/(HCVIgGHCVstHCVnsHCVIgM);HBVDNAHCVmRNA21312AFP,AFP\400Lg/L1,\200Lg/L2,,;(CT/MRI)30%~40%AFP,ICCHCCHCC,AFP,AFP,AFP60%~70%,,,BHCC,C2(GGT)A2L2(AFU)(DCP)73(GP73),52(5'NPD)A(ALD2A)S2(GST),(FT)(AIF)HCC(CEA)CA1929213132131311(US),US,,,,,,,(CEUS),,ICC,;US,,#930#2011101610ChineseClinicalOncology,Oct.2011,Vol.16,No.102131312(CT),CT,CT,,,;,015mm,,,,,,,;,,,HCC,,,,2131313(MRIMR),,,CTUS,,CT;,;MRICT,MRI,MRI,CT,,,MRI(),,,,,,2131314(DSA),,DSA:,;,;;;:/0/0DSA,,;,DSA,,,,DSA,2131315(PET2CT)PET2CTPETCT,PET,CT,,,,PET2CT,,,2131316(ECT)ECT,XCT3~621314(corebiopsy)(fineneedleaspiration,FNA),,,,,;,214肝癌的诊断标准21411,/HCC,21412,HCC,,,,AFP,,,,,,,(1)+(2)a(1)+(2)b+(3),HCC(1)HBV/HCV(HBV/HCV);(2)HCC:CT/MRI(arterialhypervascularity),(venousordelayedphasewash2out)a:\2cm,CTMRI,HCC;b:1~2cm,CTMRI,HCC,(3)AFP\400Lg/L1\200Lg/L2,AFP,21413(1)(#931#2011101610ChineseClinicalOncology,Oct.2011,Vol.16,No.10AASLDEASLNCCNCPGs)CT/MRI,;,HCC,,[5mm,HCC,,,,CTMRI,,,(2),,AFPICC,ICCICCHCC,,,AFPHCC,,AFPHCC,ICC,HCC(3)AFP\400Lg/L,B,;,CT/MRIHCC(,),HCC,,HCCAFP,,AFP,AFP,B1~2,CT/MRI,(DSA),(4),AFP,,1cm,,,\2cm,B,,;6,HCC;,HCC,(5),HCC5%~20%,10%HBV/HCV,30%AFP200Lg/L;,HCC,,,(NASH),HCC(NASHHCC),,215鉴别诊断21511AFP,HCC(1):,AFPAFPALT,,400Lg/L,,,AFPALT,AFPALT,AFPALT/AFP,HCC(2):BCT(3):AFP,(hepatoidadenocarcinoma),,AFP,AFP21512AFP,HCC(1):,,,AFP,CEACA199CA50CA724CA242:,HCC;,/0(,);CTDSA,HCC;X(2)(ICC):,30~50,,,AFP,CEACA199CT,,,,CTHCC,,,/0,;,,(),(3):,,AFPHCC(4):::,,,HCC,99mTc,,;:,,CT,/0,HCC/0,MRI/0;:,,,,B,,;DSA;;:,#932#2011101610ChineseClinicalOncology,Oct.2011,Vol.16,No.10,,,,,/0,,(Casoni),90%~95%,B,CT,216病理学诊断(),,HBV/HCVAFP,,,,:21611(HCC)90%,(1):;1977/01cm,1~3cm,3~5cm,5~10cm,10cm,(),:[3cm;2,[3cm,,,(2):,,,,,,,,Edmondson2Steiner,(3):(HepPar1),(pCEA),CD34,23(GPC23)HCC,;GPC23,70(HSP)(GS),32HCC21612(ICC),,[5%(1):(2):,,,,,,,,3(3):19(CK19)21(MUC21),21613HCC2ICC,,,HCCICC,,,21614,(fibrolamellarcarcinomaofliver,FLC),FLCHCC,35,,HCC,,,,,,,;:,,,,,,,,21615(),,(1)3311肝和肝内胆管肿瘤组织学分类(WHO2005)ICD2O8170/08160/08161/08264/0()8170/3()8160/38161/38180/38970/38020/3#933#2011101610ChineseClinicalOncology,Oct.2011,Vol.16,No.108860/09170/39120/09130/09133/19120/3()8991/38900/38815/09080/1()9071/38980/3Kaposi9140/38963/3()()()()()()()()()312肝癌的分期31211TNM(UICC/AJCC2010)TNM~,;,,TNM,:(1),,HCC,;(2)HCC,();(3)TNM,UICC/AJCC(2010)TNMT2Tx:T0:T1:T2:,[5cmT3a:5cmT3b:T4:,N2Nx:N0:N1:M2Mx:M0:M1::T1N0M0:T2N0M0A:T3aN0M0B:T3bN0M0C:T4N0M0A:T,N1M0B:T,N,M131212(BCLC2010)BCLC,,,,,()HCC,(),BCLC,,1313一般健康状态(PS)评分(performancestatus,PS),HCC(ECOG),:0:,1:,,#934#2011101610ChineseClinicalOncology,Oct.2011,Vol.16,No.10表1HCC的BCLC分期(2010)PS0:02cmA:033cmChild2PughABChild2PughABB:0Child2PughABC:1~2N1M1Child2PughABD:3~4Child2PughC2:,,3:,4:,5:314肝脏储备功能评估Child2Pugh(2)(ICG),,,,3cm,CT/MRI,,,CT(standardremnantlivervolume,SRLV)416ml/m2,ICG(),015mg/kg,15ICG(ICG2R15),12%,表2肝功能Child2Pugh分级Child2Pugh123(Lmol/L)3434~5151(g/L)3528~3528(s)1~34~66()1~23~4:,5~6A,7~9B,10~15C4411肝切除术41111(1),,;(2),,,Child2PughICG,CT/MRIHCC10cm,,,HCC(Child2Pugh)15(ICG15)BCLC(HVPG)HCC,Child2PughAHVPG12mmHgICG1520%,,40%,HCC41112,,3,:,:4:(1)[2;(2);(3);(4):,,AFP,2AFP41113(1):,,:,;,(Child2PughA),B,A;(ICGR15);ICG1514%,(2),:,,,30%;30%,,50%;,3,,,,3;3,,(3):#935#2011101610ChineseClinicalOncology,Oct.2011,Vol.16,No.10,5cm2~6,,,,(4),:3~5,,;2~3,,50%;(),,50%;,;(5):(PVTT)/(3)HCC,,,,,,,,,,,,,/,,TACE,,,,(HBVDNAHCVRNA),,,41114,;,,:;,,,,,,,(),,,,,,,,,,41115,,,,,,,A,,41116(1),;(2),Child2PughC;(3)412肝移植术41211,,TACE,,(Milan),(UCSF)(Pittsburgh)TNM4121111(Milan)1996,Mazzaferro:5cm;[3,[3cm;1998,(UNOS)MilanMELD/PELD,UNOS,,Milan,5\75%,10%,,,Milan,,Milan,Milan,,,,,,Milan4121112(UCSF)2001,Yao,,:615cm;[3,[415cm,[8cm;UCSFMilan,,UCSF,,#936#2011101610ChineseClinicalOncology,Oct.2011,Vol.16,No.10表3原发性肝癌姑息性肝切除适应证(PVTT)/#,,,,,#,#,#,,#,,,:##,Child2Pugh,A/G:#,,,#,#,,:#,#,,#,#,,,#,,,,;,,(),UCSF4121113(Pittsburgh)TNM2000,Marsh,,,,50%,,,,,,,,4121114,,,,,,,,,,41212,,,#937#2011101610ChineseClinicalOncology,Oct.2011,Vol.16,No.10,,,,,(),,,41213,,,,,;,(Child2PughC),,(Child2PughA),,,,Milan,,,,5,,,20%,,511局部消融治疗,(RFA)(MWA)(Cryoablation)(HIFU)(PEI),USCTMRI,351111(1):,[5cm;[3,[3cm;Child2PughAB,,5cm,3cm,,(2):;;,1/3;Child2PughC,;1;,;,;,;;,;;,51112(1)(radiofrequencyablation,RFA):,,,,,,,RFA,TAE/TACE,RFA3~5cmRFA,,,USRFA,(CEUS),CEUS,,,RFAHCC:;,;(/0),5cm,RFA,,,RFA(2)(microwaveablation,MWA):,RFA