中国实用外科杂志

中国实用外科杂志

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肝癌转化治疗相关技术方法及评价

赵    明1，伍家鸣 2，商昌珍3，吕    宁1   

  1. 1中山大学肿瘤防治中心微创介入科 华南肿瘤学国家重点实验室 肿瘤医学协同创新中心，广东广州510060；2广州中医药大学附属中山医院肿瘤科，广东中山528400；3中山大学孙逸仙纪念医院肝脏外科，广东广州510120
  • 出版日期:2021-03-01 发布日期:2021-03-18

  • Online:2021-03-01 Published:2021-03-18

摘要： 由于肝癌发病早期无明显症状，大部分肝癌病人确诊时已属中晚期，失去根治性手术切除的机会。转化治疗有望将部分初始不可切除肝癌转化为可切除或接受更为有效的局部治疗手段，为病人争取根治性治疗机会、进一步延长生存期。对于病灶局限肝内的中晚期病人，肝动脉栓塞化疗（TACE）及肝动脉灌注化疗（HAIC）治疗可以缩小肿瘤负荷，或通过门静脉栓塞术（PVE）及联合肝脏分隔和门静脉结扎的二步肝切除术（ALPPS）增大残肝体积以实现转化后手术切除。对于合并大血管癌栓的肝癌，通过HAIC及TARE治疗、或者联合外照射及立体定向放疗（SBRT），有望实现肿瘤及癌栓退缩，为手术切除及局部治疗创造条件。对于存在肝外寡转移的肝癌病人，原发灶切除联合寡转移灶消融仍然可能帮助病人达到无瘤（NED）状态，给病人带来生存时间的延长和生活质量的提升。对于合并多发转移的晚期肝癌病人，随着酪氨酸激酶抑制剂（TKIs）联合免疫检查点抑制剂（ICIs）、ICIs联合抗血管生成等系统治疗新模式带来生存期的不断延长，在合适的时机联合射频消融、TACE、HAIC等局部治疗有助于进一步延长无进展时间及生存时间。总之，随着治疗手段不断增多，肝癌转化治疗的概念外延需要进一步拓宽，越来越丰富的转化治疗技术手段也将推动中晚期肝癌从姑息向以根治为目的治疗的转化。

关键词: 肝细胞癌, 转化治疗, 降期, 免疫检查节点抑制剂, 络氨酸激酶抑制剂, 肝动脉灌注化疗

Abstract: Advances in the techniques and evaluation of conversion therapy for hepatocellular carcinoma        ZHAO Ming*，WU Jia-ming, SHANG Chang-zhen. *Department of Minimally Invasive Intervention, Sun Yat-sen University Cancer Center； State Key Laboratory of Oncology in Southern China； Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
Corresponding author：ZHAO Ming，E-mail:zhaoming@sysucc.org.cn
Abstract    With asymptom in it early stage，most of hepatocellular carcinoma（HCC）patients are classified as unresectable at the initial diagnosis. Conversion therapy may transform parts of unresectable HCC into resectable or more effective local treatment, thus prolong overall survival time for those patients. For intermediate or late stage HCC patients (BCLC stage  B or C, or CNCL stage  IIb IIIa ), TACE/HAIC can reduce high intrahepatic tumor budren; applying with PVE/ALPPS can increase residual liver volume to achieve possibility of conversion surgery or local therapy. For patients with major vascular invasion, HAIC/TARE or combination with external radiotherapy/SBRT can shrink or even eradicate the tumor thrombus,  and thus provide more chances for conversion surgery or more effective local therapy further. The advanced HCC patients (BCLC stage C, or CNCL stage IIIb) with extrahepatic oligometastasis can also achieve status of no evidence of disease (NED) after  local therapy. With first-line systemic therapy progression, such as tyrosine kinase inhibitors (TKIs), immune checkpoint inhibitors (ICIs) combination with angiogenesis inhibitors or TKIs, more higher tumor response and longer overall survival was observed in clinic,  then sequential combination with radiofrequency ablation/TACE/HAIC and other local therapies can reduce the tumor burden and inactive drug resistance lesions. With the rapid developments of conversion therapy technologies and novel drugs, the concept of HCC conversion therapy needs renew, which will promote more advanced HCC from palliative to radical treatment.

Key words: hepatocellular carcinoma；conversion therapy；downstaging； immune checkpoint inhibitors , tyrosine kinase inhibitors, hepatic arterial infusion chemotherapy