原发性肝癌大学课件

1、原发性肝癌大学课件原发性肝癌大学课件原发性肝癌大学课件一、肝癌的流行病学肝癌的发病率:南非60100/100,000亚洲35/100,000，最高达40/100,000其它流行病学特点：男女发病：38：1中青年发病率高，平均年龄43.7岁2020/11/32原发性肝癌大学课件原发性肝癌大学课件原发性肝癌大学课件一、肝一、肝癌的流行病学肝癌的发病率:南非60100/100,000亚洲35/100,000，最高达40/100,000其它流行病学特点：男女发病：38：1中青年发病率高，平均年龄43.7岁2020/11/32一、肝癌的流行病学肝癌的发病率:2020/11/32二、肝癌的发病机理病毒性肝

2、炎： 亚州肝癌患者7090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2020/11/33二、肝癌的发病机理病毒性肝炎：2020/11/33二、肝癌的发病机理2020/11/34二、肝癌的发病机理2020/11/34二、肝癌的发病机理病毒性肝炎肝硬化 7085%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2020/11/35二、肝癌的发病机理病毒性肝炎2020/11/35二、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

3、：亚硝胺类化合物、有机氯杀虫剂。2020/11/36二、肝癌的发病机理病毒性肝炎2020/11/36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。2020/11/37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2020/11/38三、肝癌的分型及分期根据病理细胞学：肝细胞型胆管细

4、胞型混合型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35cm，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

5、，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：IIV级三、肝癌的分型及分期2020/11/39I 级：癌细胞的形态接近正常，常与II级并存。亚临床前期 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2020/11/310四、肝癌的转移途径肝内播散：通过门静脉肝内播散。 2020/五、肝癌的临床表现早期肝癌的非特异性症状 早期症状较

6、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。2020/11/311五、肝癌的临床表现早期肝癌的非特异性症状2020/11/31五、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

7、大为首发症状。 2020/11/312五、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 2020/11/313六、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6090。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

8、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。2020/11/314六、肝癌的诊断血清学检测：2020/11/314六、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。2020/11/315六、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

9、%。多排螺旋CT定位准确有利于手术方案设计。2020/11/316六、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0.51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。2020/11/317六、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

10、示肝静脉和门静脉。并对肝内管道系统有无癌栓作出判断。2020/11/318六、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2020/11/319六、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。2020/11/320六、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七、肝癌的鉴别诊断肝血管瘤:无肝炎病史、CT可见典

11、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。 2020/11/321七、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W

12、BC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2020/11/322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。2020/11/323八、肝癌的治疗原则早

13、期发现、早期诊断及早期治疗并根据不同病情适应征：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：2020/11/324适应征：一、患者一般情况1.患者一般情况较好，无明显心、肺八、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,10c

14、m）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。2020/11/325八、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

15、、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。2020/11/326八、肝癌的治疗（二）下述病例仅可行姑息性肝切除：1.3-八、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。 2020/11/327八、肝癌的治疗（二）下述病例仅可行姑息性肝切除2020

16、/11八、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。2020/11/328八、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2020/11/329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八、肝癌的治疗冷

17、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。2020/11/330八、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。2020/11/331八、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八、肝癌的治疗放射治疗化学治疗免疫治疗中医中药治疗2020/11/332八、肝癌的治疗放射治疗2020/11/332九、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。

18、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。2020/11/333九、小结肝癌的发病率逐年提高，有年轻化的趋势。2020/11A 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. 2020/11/334A 21-y

19、ear-old man presented wi2020/11/3352020/11/335The abdominal scout film shows the size of the liver, predominantly a markedly enlarged right lobe 2020/11/336The abdominal scout film shows The CT scan shows a 20X15cm right lobe mass. There was no evidence of extrahepatic tumor on the abdominal CT, and

20、 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. 2020/11

21、/337 The CT scan shows a 20X15cMagnetic resonance angiogram showed no anomalous left or right hepatic arteries 2020/11/338Magnetic resonance angiogram sThe patient was taken to the operating room for exploration and possible right hepatic lobectomy. 2020/11/339The patient was taken to the oA right s

22、ubcostal (Kocher) incision was made first, exposing the bulging right lobe. 2020/11/340A right subcostal (Kocher) incExploration showed no evidence of metastatic disease 2020/11/341Exploration showed no evidenceThe chevron incision was completed, and the lower flap tacked down to lower abdominal ski

23、n. 2020/11/342The chevron incision was complThe hepatoduodenal ligament (surgeons left index finger in foramen of Winslow) was palpated, and there was no significant adenopathy 2020/11/343The hepatoduodenal ligament (sThe xiphoid extension was completed. 2020/11/344The xiphoid extension was compA se

24、lf-retaining retractor was placed. 2020/11/345A self-retaining retractor wasThe periphery of the right lobe was mobilized by dividing adhesions to the transverse mesocolon. 2020/11/346The periphery of the right lobWith the right lobe elevated, the porta hepatis was exposed. 2020/11/347With the right

25、 lobe elevated, The gastrohepatic omentum was divided, isolating the hepatoduodenal ligament containing hepatic artery, common bile duct and portal vein. 2020/11/348The gastrohepatic omentum was The gallbladder was removed. 2020/11/349The gallbladder was removed.Intraoperative ultrasound was perform

26、ed, revealing no evidence of disease in the left lobe. 2020/11/350Intraoperative ultrasound was The hepatic artery was isolated and encircled with a red vessel loop. 2020/11/351The hepatic artery was isolateThe portal vein was dissected, and a venous branch from the caudate lobe was ligated and divi

27、ded. 2020/11/352The portal vein was dissected,The right branch of the portal vein was isolated and encircled with a blue vessel loop. 2020/11/353The right branch of the portalThe right hepatic artery was ligated and divided. 2020/11/354The right hepatic artery was lThe right portal vein was clamped

28、with vascular clamps and divided. 2020/11/355The right portal vein was clamThe cut end of the right portal vein was oversewn with running 5-0 polypropylene suture. 2020/11/356The cut end of the right portaThe liver is shown after division of the right portal vein and right hepatic artery. 2020/11/35

29、7The liver is shown after divisThe right triangular ligament (see hepatic anatomy) was divided 2020/11/358The right triangular ligament The right lobe was mobilized. 2020/11/359The right lobe was mobilized.The inferior vena cava was exposed at the dome of the diaphragm. The forceps is on the right h

30、epatic vein. 2020/11/360The inferior vena cava was expThe duodenum was Kocherized, exposing the infrahepatic inferior vena cava. 2020/11/361The duodenum was Kocherized, eThe right hepatic vein is seen in the top CT slice, and the large inferior right branch is shown in the lower slice. 2020/11/362Th

31、e right hepatic vein is seenA large branch of the inferior group of hepatic veins was isolated. 2020/11/363A large branch of the inferiorThe large branch was ligated on the liver side, and clamped on the vena cava side. 2020/11/364The large branch was ligated oAfter division and oversewing of the br

32、anch, another large branch was revealed behind. 2020/11/365After division and oversewing The second branch was divided in similar fashion. 2020/11/366The second branch was divided The right hepatic vein was isolated. 2020/11/367The right hepatic vein was isoThe right hepatic vein was divided with a

33、linear vascular stapler. 2020/11/368The right hepatic vein was divSmaller short hepatic branches were divided, freeing the right anterolateral wall of the inferior vena cava. 2020/11/369Smaller short hepatic branchesThe right lobe was fully mobilized 2020/11/370The right lobe was fully mobilUmbilica

34、l tape was passed behind the liver, to mark the plane between vena cava and gallbladder bed delineating the division of right and left lob 2020/11/371Umbilical tape was passed behiDivision of the devascularized right lobe was begun anteriorly using electrocautery. 2020/11/372Division of the devascularizedThe plane of dissection was kept to the left of the middle hepatic vein (see hepatic segmental anat