How to reduce the recurrence rate of liver cancer

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Primary liver cancer is the fifth most common malignant tumors, accounting for third of cancer deaths, five years of natural mortality is mo


Primary liver cancer is the fifth most common malignant tumors, accounting for third of cancer deaths, five years of natural mortality is more than 95%. More than 500 thousand people worldwide suffer from liver cancer every year, more than half of them in China [1]. Although there are many effective methods for liver cancer, liver resection is still the most important means for the treatment of liver cancer. Because patients with insidious onset of symptoms found most has reached an advanced stage, only less than 20% of the patients with hepatic resection. However, more than 50% of patients with postoperative recurrence and metastasis are still present, even if the patient has had the so-called radical resection. Therefore, how to effectively reduce the recurrence rate of the overall operation of hepatocellular carcinoma, to patients with postoperative recurrence of re intervention to prolong the survival time and improve the quality of life, become the majority of medical workers, especially the urgent mission of hepatobiliary surgeons.

At present, there are three factors that influence the recurrence of liver cancer after surgery: the factors of tumor from the patient, the factors of surgical operation, and the intervention measures to prevent recurrence of [3]. Below I will talk about how to reduce the overall recurrence rate of liver cancer from three aspects:

First, through early diagnosis and early surgical intervention to reduce the incidence of postoperative recurrence in patients with liver cancer surgery.

At present, the surgical technique of hepatectomy has been more mature, and a large number of Department of hepatobiliary surgery centers reported that the mortality rate of liver resection was less than 3-5%, and there were some reports that there was no perioperative death of [4, 5]. However, there are still differences between the East and the West in terms of surgical indications. By comparison, the range of indications for surgery was wider than that of foreign standards, [6, 7]. Some patients with portal vein tumor thrombus, tumor thrombus, bile duct or distant metastasis in patients with advanced, in most of the Western Center Department of hepatobiliary surgery does not consider surgical treatment, but in our opinion, as long as the tumor itself has the resectability of liver function reserve can, still will actively consider resection. We have a group of 511 cases of Barcelona (BCLC) for advanced liver cancer liver resection data show that [8], 1 years, 3 years and 5 years overall survival rate was 69.9%, 41.2% and 30.5%, and 1 years, 3 years and 5 years disease-free survival rate reached 48.2, 30.3% and 24%, significantly better than the Western countries reported by the survival of patients with advanced hepatocellular carcinoma BCLC Sola Fini treatment or medical treatment.

Tumor size, tumor number, complete capsule, tumor grade, portal vein tumor thrombus, and distant metastasis were confirmed to be an independent risk factor for recurrence after resection of hepatocellular carcinoma (HCC) [9]. It seems that from the individual consideration, each patient's implementation of the operation from the tumor itself is unable to control factors, from this level can not affect the recurrence rate of liver cancer. However, on the whole liver cancer population, to reduce the overall rate of postoperative recurrence of hepatocellular carcinoma, we can do is to make more patients with early detection of tumor in hepatocellular carcinoma in the early and mid period when surgical resection to cure. To this end, we need to strengthen the knowledge of science and education, and actively carry out physical examination and census, focusing on monitoring of hepatitis virus carriers, timely detection and diagnosis. When more and more early and middle liver cancer resection, it will undoubtedly reduce the overall recurrence rate of liver cancer after surgery, which will be significant strategic initiatives.

We should see that with our social development and economic progress, people's health consciousness, medical unit and self examination gradually normalized, which is to promote good measure of overall curative effect in improving liver cancer. However, due to hepatitis B knowledge propaganda is weak, the lack of adequate understanding of the spread of a lot of people on hepatitis B, do not understand the occurrence and development of hepatitis cirrhosis hepatocellular carcinoma "trilogy, the degree of social tolerance of hepatitis B virus carriers is not enough, spread on hepatitis B knowledge are not enough. Some hepatitis B virus carriers know that they have been infected with the hepatitis B virus, still do not attach importance to the necessary routine physical examination, until the progress of advanced liver cancer, abdominal pain and abdominal symptoms appear to come to see a doctor. These patients with advanced liver cancer may be able to carry out liver resection, but postoperative recurrence and metastasis is particularly common. We had in 2011 in the "Lancet" magazine, called for the elimination of hepatitis B discrimination [10], we believe that as long as the whole society to care for hepatitis B virus carriers of this special group, so that these patients can actively treat the disease itself, often check and take the necessary anti viral therapy, it must have an indirect and positive effect on the whole liver treatment effect.

Second, to improve the surgeon's individual and overall surgical level is an effective way to reduce the recurrence rate of liver cancer.

Improve the technical level of hepatobiliary surgeons, can reduce the recurrence rate of patients with liver cancer, prolong the disease-free survival time, which is beyond doubt. Reduce the bleeding process in liver resection surgery as far as possible, avoid perioperative blood transfusion, operation in strict accordance with the principle of non tumor operation, as little as possible to directly contact or press the tumor, ensure the liver margin is negative or wider, this will help to reduce the recurrence rate of [11, 12]. In addition, we also need to have a comprehensive understanding of the patient's whole body and tumor situation, to expand the success rate of open resection. It is reported that the recurrence rate of HCC in patients without complications is lower than that of patients with complications.

At present, despite the hepatectomy can be carried out on the ground, city level hospitals, but where most of the Department of hepatobiliary surgery or general surgeon can remove some tumor growth, tumor location relatively smaller, lighter degree of cirrhosis and hepatocellular carcinoma, liver cancer surgery for complex liver tumor resection, resection of caudate lobe huge liver cancer resection and thrombus in the portal vein or bile duct thrombi need appropriate treatment, often do not have the ability to complete resection. Of course, the technical level of the surgeon is needed to be improve through practice, they can choose to go to some large domestic Department of hepatobiliary surgery study, through continuous learning to improve. In the treatment of liver cancer under the current situation, we still advocates, can try to choose surgical resection, if not removed and then consider other non radical treatment, such as TACE, radiation therapy, molecular targeted therapy. We proposed for the first time in Chinese resectable HCC staging standard of [7] in the world, and named as the "Oriental stage" (Eastern staging), we expect the standard of domestic hepatobiliary surgeons to evaluate disease and prognosis in hepatocellular carcinoma and provide some reference and suggestions.

Third, to find effective ways to prevent recurrence of drugs or drugs, is to reduce the recurrence rate of liver cancer after the fundamental solution.

There are several randomized trials and meta-analyses showed that preoperative TACE therapy [13, recurrence of hepatocellular carcinoma after resection of the prevention of 14], and TACE for the treatment of postoperative prevention, foreign studies have shown that seems to be not beneficial for postoperative recurrence of hepatocellular carcinoma [15]. However, I think this problem should be treated differently, because the indications for liver cancer resection at home and abroad are different, and the definition of "radical resection of liver cancer" is different in different studies. Our patient is a large portion of combined portal vein tumor thrombus or multiple tumors, we can do is to cut or remove all of the tumor thrombus itself, or to retain the greatest degree of residual liver function reserve and the use of local resection of multiple tumors, in addition, for such patients postoperative prophylactic TACE treatment can small tumor lesions may exist in hepatic function [16]. Therefore, it is necessary to confirm the effect of prophylactic TACE on postoperative recurrence in patients with multiple risk factors.

Previous studies have shown that perioperative and postoperative antiviral therapy plays an important role in reducing the disease-free survival and overall survival after resection of hepatocellular carcinoma ([17]). Liver resection itself may cause reactivation of hepatitis B virus in vivo, which may lead to the decline of immune function, which may affect the recurrence of liver cancer. In addition, we should note that, in fact, the so-called recurrence is to be divided into two cases, one is associated with the liver cancer cells in the liver metastasis, and the other is the recurrence of liver cancer. For HBV related HCC patients with a high viral load, antiviral therapy can reduce the HBV-DNA content in the body, obviously the latter case the tumor then initiates the inhibitory effect, which is understandable. Antiviral therapy is one of the best examples of hepatitis B related liver cancer recurrence after surgery.

At present, it is very limited to prevent the recurrence of liver cancer. Thymosin can improve immune function, may be useful for prevention of recurrence, but still lack of evidence-based medical evidence strictly. In fact, in the prevention of postoperative recurrence, we can also consider the appropriate use of traditional Chinese medicine, may be able to achieve unexpected results. But because the Chinese medicine dialectical prescription of traditional Chinese medicine about itself, and the mechanism is It differs from man to man., is difficult to pass through the modern medical pattern to clarify, so it is difficult to carry out a number of high quality randomized controlled trials, or the conclusion to make everyone convinced. In any case, China's traditional Chinese medicine in order to obtain a wide range of recognition and comprehensive development, we must take the road of modern development and scientific research, to use advanced medical concepts to prove. Now some of the traditional Chinese medicine prescription has been developed for traditional Chinese medicine, and has carried out a randomized controlled trial of clinical in our hospital, we look forward to these traditional Chinese medicine can play a magical effect in preventing the recurrence of hepatocellular carcinoma after operation.

As everyone knows, liver cancer is a multi discipline need to participate in "the most complex" disease, liver surgery, transplant surgery, Gastroenterology, oncology, Department of traditional Chinese medicine, Department of interventional therapy, radiation therapy, minimally invasive treatment, doctors can take different targeted for liver cancer treatment, even with a different doctor professional treatment, sometimes also will have inconsistent views. A liver cancer patients come to the hospital for treatment, the treatment plan and the final effect, in fact, and his first visit to the doctor is a certain connection. In my clinic once encountered some of the patients, first found tumors less than 5 cm high, the body and liver function are very good, is the best evidence for hepatic resection. However, their treatment of the local hospital doctors gave them recommended interventional therapy or radiation therapy, not surgery, which obviously is expected to cure these patients lose the best chance of cure, they wait until the tumor grew up, or with PVTT or distant metastasis before he went to seek treatment for others, it makes me very sad. Therefore, I very early on the proposed treatment concept specification of liver cancer, and implement and inheritance in our hospital department of hepatobiliary surgery in the East, and hope to make more cancer patients get reasonable individualized treatment.

In addition, I would like to talk about the issue of "over treatment", which is also a common phenomenon in the recurrence of HCC after surgery. I think, "harmony" and "balance" concept should be emphasized in the overall treatment of cancer, we need to consider in the course of treatment for the tumor itself, whether it will bring harm and effect on normal body. If the liver cancer patients with postoperative recurrence and metastasis, this time should consider what kind of treatment? Is re resection, TACE, radio frequency ablation, radiation therapy, molecular targeted therapy, or traditional Chinese medicine treatment? Or a combination of several applications? This is of course according to the specific circumstances of each patient's comprehensive consideration, but must be vigilant to refrain from excessive treatment, but the damage to the normal liver function or the organism suffered fatal injuries, affects the patients' quality of life.

In conclusion, we have a lot of work to do in the basic research and clinical research on the postoperative recurrence of liver cancer. I believe that through multidisciplinary collaboration, Chinese scholars will be able to achieve a breakthrough in the study of liver cancer recurrence and metastasis after surgery, the benefit of our patients!


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