原发性肝癌课件

,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,.,*,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,Primary liver Cancer,1,.,一、肝癌的流行病学,肝癌的发病率,:,南非,60,100/100,000,亚洲,3,5/100,000,，最高达,40/100,000,其它流行病学特点：,男女发病：,3,8,：,1,中青年发病率高，平均年龄,43.7,岁,2,.,二、肝癌的发病机理,病毒性肝炎：,亚州肝癌患者,70,90,为,HBV,携带者，国内肝癌患者,HBV,携带者超过,85,。,肝硬化,化学致癌剂,3,.,二、肝癌的发病机理,4,.,二、肝癌的发病机理,病毒性肝炎,肝硬化,70,85%,的肝癌发生于肝硬化时肝细胞代偿增生的基础上。,化学致癌剂,5,.,二、肝癌的发病机理,病毒性肝炎,肝硬化,化学致癌剂,在肝癌高发地区，黄曲霉素,B1(AFB1,）的污染程度较重，检出率高，,AFB1,能导致肝细胞损害，肝细胞修复、增生过程中可能发生癌变。其他化学致癌物还包括：亚硝胺类化合物、有机氯杀虫剂。,6,.,最常见，多伴肝硬化，常为多个结节，大小不一，分布广泛，有半数以上病例波及全肝。,多为单个癌结节或多个癌结节融合而成，较少肝硬化，切除机会多。,巨块型：,结节型：,三、肝癌的分型及分期,根据大体标本观察：传统分为小肝癌、大肝癌及巨大肝癌,弥漫型：,少见，为广泛分布的小结节癌灶，肉眼下难与结节性肝硬化区分。,7,.,三、肝癌的分型及分期,根据病理细胞学：,肝细胞型,胆管细胞型,混合型,8,.,I,级：癌细胞的形态接近正常，常与,II,级并存。,II,级：癌细胞核比正常者大，着色深，胞浆呈嗜酸性和明显的颗粒状，常见腺泡并含胆汁。,III,级：胞核更大，更富有染色质而着色更深，胞浆少，仍有颗粒，呈嗜碱性，胆汁很少发现，癌巨细胞多见。,IV,级：胞核大而深染，胞浆很少，胞浆中颗粒或有或无，条索结构不易见到。,亚临床前期,临床前期：从亚临床肝癌诊断建立至出现症状之前，患者仍无症状与体征，瘤体约,3,5cm,，诊断仍较困难，多属,AFP,普查发现，此期平均为,8,个月左右。,亚临床前期：从病变开始至作出亚临床肝癌诊断之前，患者无症状与体征，临床难以发现，平均,10,个月。,分期,亚临床前期,临床前期,临床期：一旦出现临床症状，已至中期。此时病情发展迅速，不久可出现黄疸、腹水、肺转移已至广泛转移及恶病质的晚期表现，中、晚期共,6,个月时间，肝癌发展至晚期，瘤体可达,10cm,左右，治愈困难。,根据恶性程度：,I,IV,级,三、肝癌的分型及分期,9,.,四、肝癌的转移途径,肝内播散：,通过门静脉肝内播散。,血行转移：,通过肝静脉，多转移至肺部。,淋巴转移：,肝门部淋巴结转移多见，晚期可转移至胰、脾、主动脉旁、锁骨上淋巴结等。,直接侵犯和腹腔播种,10,.,五、肝癌的临床表现,早期肝癌的非特异性症状,早期症状较为隐匿，表现无特征性。由于多合并有肝硬化，更容易被忽视，早期症状有上腹部不适、胀痛、刺痛、食欲下降、乏力。,11,.,五、肝癌的临床表现,肝癌的典型症状,肝区疼痛,全身和消化道症状,肝肿大,持续性钝痛、刺痛或胀痛，可反射至右肩背部。癌结节坏死、破裂、出血引起右上腹剧痛、压痛。,早期不引人注意，主要表现为乏力、消瘦、食欲减退、腹胀，部分病人可有恶心、呕吐、发热、腹泻等症状，晚期出现贫血 、黄疸、腹水、下肢浮肿、皮下出血及恶病质。,中晚期肝癌最常见的体征，约占,95,，肝进行性肿大，导致右侧膈肌抬高、肝浊音界上升。在部分病人，肝区包块及肝肿大为首发症状。,12,.,六、肝癌的诊断,早期诊断是原发性肝癌获得早期治疗的前提，一旦肝癌出现了典型症状与体征，诊断并不困难，但往往已非早期。所以，凡是中年以上，特别是有肝病史病人，发现有肝癌早期非特异的临床表现，应考虑肝癌的可能。,特征性：慢性肝病史、肝占位性病变，甲胎蛋白,13,.,六、肝癌的诊断,血清学检测：,AFP,：为目前诊断肝细胞癌特异性最高的方法之一，阳性率,60,90,。对无肝癌其它证据，血清,AFP,放射免疫,400g/L,，持续一个月以上，并能排除妊娠，活动性肝病，生殖腺胚胎性肿瘤等即可诊断为肝细胞癌。,其它：,-,谷氨酰转肽酶，硷性磷酸酶和乳酸脱氢酶等由于缺乏特异性，多作为辅助诊断。,14,.,六、肝癌的诊断,影像学检查,B,超,:,可显示肿瘤的大小，形态，所在部位以及肝静脉或门静脉内有无癌栓等，其诊断符合率可达,84%,，能发现直径,2,厘米或更小的病变，是目前较好有定位价值的非侵入性检查方法。,15,.,六、肝癌的诊断,影像学检查,CT,:,分辨率高，可检出直径约,1,厘米左右的早期肝癌，应用增强扫描有助与血管瘤鉴别。对于肝癌的诊断符合率高达,90%,。多排螺旋,CT,定位准确有利于手术方案设计。,16,.,六、肝癌的诊断,影像学检查,血管造影,:,对血管丰富的癌肿，有时可显示直径为,0.5,1,厘米的占位病变,其诊断正确率高达,90%,。可确定病变的部位、大小和分布，特别是对小肝癌的定位诊断是目前各种检查方法中最优者。但属有创检查，必要时才考虑采用。,17,.,六、肝癌的诊断,影像学检查,核磁共振成象,:,诊断价值与,CT,相仿，可获得横断面、冠状面和矢状面图象，对良、恶性肝占位病变，特别是与肝血管瘤的鉴别优于,CT,，且无需增强即可显示肝静脉和门静脉。并对肝内管道系统有无癌栓作出判断。,18,.,六、肝癌的诊断,影像学检查,放射性核素扫描；,ECT,有助于诊断大肝癌。但不易发现小于,3cm,的肿瘤,19,.,六、肝癌的诊断,肝活检,穿刺活检：肝穿刺行针吸细胞学检查有确定诊断意义，目前多采用在,B,型超声引导下行细针穿刺，有助于提高阳性率，但有导致出血，肿瘤破裂和针道转移等危险。,20,.,七、肝癌的鉴别诊断,肝血管瘤,:,无肝炎病史、,CT,可见典型的早到迟退现象，,AFP,阴性。,肝硬变：,鉴别困难，依靠,AFP,，活检及定期观察。,继发性肝癌：,病情进展较缓慢，有原发病的改变，,AFP,阴性，典型的转移病灶为牛眼征改变。,肝脓肿,：,感染表现，,AFP,阴性，血象升高，抗感染治疗有效,。,肝包虫病：,牧区生活史或牛羊狗接触史，,Cassoni,实验阳性，,CT,可见子囊，边界清楚。,肝脏邻近器官肿瘤：,AFP,，必要时行剖腹探查。,21,.,阿米巴性及细菌性肝脓肿鉴别,细菌性肝脓肿,阿米巴性肝脓肿,病,史,继发于胆道感染,继发于肠阿米巴痢疾,病,程,病情急骤严重，全身脓毒血症明显,起病较缓慢，病程较长，症状较轻,血液化验,WBC,计数增加，中性粒细胞可高达90%。有时血培养阳性,白细胞计数可增加，血液细菌培养阴性,粪便检查,无特殊发现,可找到阿米巴滋养体,脓肿穿刺,多为黄白色脓液，涂片和培养发现细菌,多为棕褐色脓液，镜检有阿米巴滋养体。,诊断性治疗,抗生素治疗有效,抗阿米巴治疗好转,脓肿,较小，多发,较大，多单发肝右叶,22,.,八、肝癌的治疗原则,早期发现、早期诊断及早期治疗并根据不同病情发展阶段进行综合治疗，是提高疗效的关键。,早期施行手术切除仍是最有效的治疗方法。,对无法手术的中、晚期肝癌，可根据病情进行栓塞、冷冻、中医中药治疗和化疗。,23,.,适应征：一、患者一般情况,1.,患者一般情况较好，无明显心、肺、肾等重要脏器器质性病变。,2.,肝功能正常，或仅有轻度损害，按肝功能分级属,级；或肝功能分级属,级，经短期护肝治疗后有明显改善，肝功能恢复到,级,.3.,肝储备功能（如,ICG,R15,）正常范围。,4.,无广泛肝外转移性肝癌癌灶肿瘤。,八、肝癌的治疗,手术治疗：,24,.,八、肝癌的治疗,二、局部病变情况（一）下述病例可作根治性肝切除,1.,单发的微小肝癌（直径,2cm,）。,2.,单发的小肝癌（直径,2cm,5cm,）。,3.,单发的向肝外生长的大肝癌（直径,5cm,10cm,）或巨大肝癌（直径,10cm.,），表面较光滑，周围界限较清楚，受癌灶破坏的肝组织少于,30%,。,4.,多发性肝癌，癌结节少于,3,个，且局限在肝脏的一段或一叶内。,25,.,八、肝癌的治疗,（二）下述病例仅可行姑息性肝切除：,1.,3-5,个多发性肿瘤，超越半肝范围者，作多处局限性切除；或肝癌局限于相邻,2-3,个肝段或半肝内，影像学显示，无瘤侧肝脏组织明显代偿性增大，达全肝的,50%,以上。,2.,左半肝或右半肝的大肝癌或巨大肝癌，边界较清楚，第一、二肝门未受侵犯；影像学显示，无瘤侧肝脏明显代偿性增大，达全肝组织的,50%,以上。,3.,位于肝中央区（肝中叶，或,、,、,段）的大肝癌，无瘤肝脏组织明显代偿性增大，达全肝的,50%,以上。,26,.,八、肝癌的治疗,（二）下述病例仅可行姑息性肝切除,4,或,段的大肝癌或巨大肝癌。,5,肝门部有淋巴结转移者，如原发性肝脏肝癌可切除，应作肿瘤切除，同时进行肝门部淋巴结清扫；淋巴结难以清扫者，术后可进行放射治疗。,6,周围脏器（结肠、胃、隔肌或右肾上腺等）受侵犯，如原发性肝脏肿瘤可切除，应连同作肿瘤和侵犯脏器一并切除。远处脏器单发转移性肿瘤（如单发肺转移），可同时行原发肝癌切除和转移癌切除术。,27,.,八、肝癌的治疗,介入治疗：,经肝动脉内给予含化学药物的栓塞剂进行肝动脉栓塞化疗，可使肝癌缩小，部分病人可因此而获得二期手术切除的机会，少数患者可以达到治愈。采用经股动脉插管超选择性肝动脉造影定位下，行肝动脉栓塞化疗，具有可以反复多次施行的特点。,28,.,无水酒精注射,:,在,B,超引导下经皮肝穿刺肿瘤无水酒精注射或术中无水酒精注射,能使肿瘤脱水、凝固、坏死，适用于瘤体较小而又不能或不宜手术切除者，一般需要重复注射数次。,八、肝癌的治疗,29,.,八、肝癌的治疗,冷冻治疗：,对于较小的肿瘤或无法切除的肿瘤，可以通过液氮或氩氦刀冷冻治疗，通过细胞冻融使肿瘤细胞破坏，达到治疗或减积的目的。,30,.,八、肝癌的治疗,热凝固治疗,:,通过微波或射频，在肿瘤局部产生高温使肿瘤凝固变性，达到治疗肝癌或肝癌减积的目的，其适应症与冷冻治疗相同。,31,.,八、肝癌的治疗,放射治疗,化学治疗,免疫治疗,中医中药治疗,32,.,九、小结,肝癌的发病率逐年提高，有年轻化的趋势。,诊断方法、治疗方法多样。,随着原发性肝癌的早期诊断、早期治疗和肝脏外科的发展，肝癌的总体治疗效果显著提高。,以针对患者的个体化综合治疗效果较好。,33,.,A 21-year-old man presented with a 2-month history of weight loss, night sweats and early satiety. Physical exam revealed hepatomegaly, shown on this caudal view of the upper abdomen.,34,.,35,.,The abdominal scout film shows the size of the liver, predominantly a markedly enlarged right lobe,36,.,The CT scan shows a 20X15cm right lobe mass. There was no evidence of extrahepatic tumor on the abdominal CT, and CT of the chest and bone scan were both normal.,Core needle biopsy of the mass showed non-fibrolamellar hepatocellular carcinoma. Upper endoscopy and colonoscopy were normal. Bilirubin was 0.7 and liver enzymes were normal. Hepatitis serologies were normal. Alphafetoprotein was over 230,000.,37,.,Magnetic resonance angiogram showed no anomalous left or right hepatic arteries,38,.,The patient was taken to the operating room for exploration and possible right hepatic lobectomy.,39,.,A right subcostal (Kocher) incision was made first, exposing the bulging right lobe.,40,.,Exploration showed no evidence of metastatic disease,41,.,The chevron incision was completed, and the lower flap tacked down to lower abdominal skin.,42,.,The hepatoduodenal ligament (surgeons left index finger in foramen of Winslow) was palpated, and there was no significant adenopathy,43,.,The xiphoid extension was completed.,44,.,A self-retaining retractor was placed.,45,.,The periphery of the right lobe was mobilized by dividing adhesions to the transverse mesocolon.,46,.,With the right lobe elevated, the porta hepatis was exposed.,47,.,The gastrohepatic omentum was divided, isolating the hepatoduodenal ligament containing hepatic artery, common bile duct and portal vein.,48,.,The gallbladder was removed.,49,.,Intraoperative ultrasound was performed, revealing no evidence of disease in the left lobe.,50,.,The hepatic artery was isolated and encircled with a red vessel loop.,51,.,The portal vein was dissected, and a venous branch from the caudate lobe was ligated and divided.,52,.,The right branch of the portal vein was isolated and encircled with a blue vessel loop.,53,.,The right hepatic artery was ligated and divided.,54,.,The right portal vein was clamped with vascular clamps and divided.,55,.,The cut end of the right portal vein was oversewn with running 5-0 polypropylene suture.,56,.,The liver is shown after division of the right portal vein and right hepatic artery.,57,.,The right triangular ligament (see,hepatic anatomy,) was divided,58,.,The right lobe was mobilized.,59,.,The inferior vena cava was exposed at the dome of the diaphragm. The forceps is on the right hepatic vein.,60,.,The duodenum was Kocherized, exposing the infrahepatic inferior vena cava.,61,.,The right hepatic vein is seen in the top CT slice, and the large inferior right branch is shown in the lower slice.,62,.,A large branch of the inferior group of hepatic veins was isolated.,63,.,The large branch was ligated on the liver side, and clamped on the vena cava side.,64,.,After division and oversewing of the branch, another large branch was revealed behind.,65,.,The second branch was divided in similar fashion.,66,.,The right hepatic vein was isolated.,67,.,The right hepatic vein was divided with a linear vascular stapler.,68,.,Smaller short hepatic branches were divided, freeing the right anterolateral wall of the inferior vena cava.,69,.,The right lobe was fully mobilized,70,.,Umbilical tape was passed behind the liver, to mark the plane between vena cava and gallbladder bed delineating the division of right and left lob,71,.,Division of the devascularized right lobe was begun anteriorly using electrocautery.,72,.,The plane of dissection was kept to the left of the middle hepatic vein (see,hepatic segmental anatomy,) because of the proximity of that structure to the tumor.,Vascular connections between segment IV and the right lobe were isolated and divided between clips.,73,.,An argon beam coagulator was used to aid surface hemostasis.,74,.,The partially divided interlobar plane is shown.,75,.,The ultrasonic dissector/aspirator was used to further develop the plane,76,.,The middle hepatic vein was divided at its junction with the left hepatic vein.,77,.,The last connections of the right lobe are shown from the patients left. The connections, including the right hepatic duct, were divided and the specimen removed.,78,.,The abdomen is shown after removal of the specimen.,79,.,The lateral surface of the right lobe is shown (caudal to left, posterior to top).,80,.,The abdomen was closed in standard fashion,81,.,