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Primary liver cancer (HCC) is one of the most common malignant tumors in mainland China, ranking fourth in incidence and fifth in mortality. Every year, there are more than 400,000 new cases and nearly 400,000 deaths, which poses a great health threat and a heavy economic burden to the people of the mainland.
Since 2017, the state and the competent health authorities have attached great importance to the standardized diagnosis and treatment of liver cancer, and have successively issued relevant diagnosis and treatment (treatment) norms (guidelines) since 2017 to continuously improve the diagnosis and treatment level of liver cancer, further promote the standardization of diagnosis and treatment of liver cancer, and transform liver cancer from an incurable disease to a treatable disease.
However, due to various reasons, the five-year survival rate of liver cancer patients in mainland China is still very low (14%), and there are many gaps with advanced countries in the world, which makes some patients fear liver cancer and lose confidence in treatment.
It is gratifying that the national version of the Guidelines for the Diagnosis and Treatment of Primary Liver Cancer (2024 Edition) (hereinafter referred to as the new guidelines) has been released in a timely manner, providing new diagnosis and treatment strategies, technical measures and work requirements for the high-quality development of liver cancer diagnosis and treatment in mainland China.
As an old expert engaged in liver disease, I have benefited a lot from carefully studying the new guidelines and listening to the reports of academic experts on the interpretation of the new guidelines many times, and I deeply feel that we must follow the new guidelines, work hard to implement the standardization, precision and homogenization of the diagnosis and treatment of liver cancer, take the maximum benefit of patients as the only goal, and carry out the best individualized treatment for each patient to strive for the best curative effect.
This new guideline in the new era is undoubtedly the crystallization of the collective wisdom of mainstream experts in liver cancer in China, and comprehensively reflects the latest research results in clinical diagnosis and treatment of liver cancer at home and abroad.
1. Early screening is the first priority in the prevention and treatment of liver cancer
The new guidelines first emphasize that liver cancer screening is the key to early detection and early diagnosis and treatment, which can significantly reduce the risk of death for patients. Screening should be targeted at people at high risk of liver cancer. In mainland China, high-risk groups for liver cancer mainly include: people with hepatitis B virus (HBV) and/or hepatitis C virus (HCV) infection, excessive alcohol consumption, liver steatosis or metabolic dysfunction-related liver disease, dietary exposure to aflatoxin B1, liver cirrhosis caused by various other reasons, and people with a family history of liver cancer, especially men aged > 40 years.
At present, although anti-HBV and anti-HCV therapy significantly reduce the risk of liver cancer, it is still impossible to completely avoid the occurrence of liver cancer. Screening and monitoring is actually very simple, that is, the "ultrasound imaging combined with serum alpha-fetoprotein (AFP)" detection that can be carried out in primary medical institutions can detect the vast majority of liver cancer or suspected liver cancer cases (which can be confirmed by further dynamic contrast CT and MRI scans).
In the process of diagnosis and treatment of chronic liver diseases such as hepatitis B, all liver cancer patients treated by the author were detected in time from dynamic changes through regular use of B-ultrasound examination + AFP detection, and all of them received early curative treatment with good prognosis.
2. Accurate diagnosis and evidence-based treatment
The focus of the new guidelines is to make a comprehensive and precise discussion on the accurate diagnosis and standardized treatment of liver cancer. In the diagnostic part, a variety of medical imaging examinations (ultrasound imaging, CT, MRI, PET/CT, etc.), hematological molecular markers of liver cancer (traditional serum AFP and newer abnormal prothrombin (DCP), plasma free microRNA (microRNA) and serum alpha-fetoprotein heteroplasm (AFP-L3) and other early diagnostic markers of liver cancer) were introduced, as well as the clinical significance and evaluation of pathological examinations. The early diagnosis, accurate diagnosis and correct staging of liver cancer have achieved unprecedented sensitivity.
For example, hepatocell-specific MRI contrast agent (gadoxetate disodium sodium, Gd-[EOB-DTPA] can be used to rapidly detect and confirm the diagnosis of microscopic liver carcinoma with a diameter of ≤1.0 cm, defined as sub-centimeter liver cancer (scHCC). According to the literature, the 5-year survival rate after local resection of scHCC is 98.5%. In high-risk populations, Gd-EOB-DTPA-enhanced MRI is recommended for the diagnosis of scHCC after exclusion of identified benign lesions, particularly in patients with cirrhosis, and to help distinguish it from precancerous lesions such as high-grade dysplastic nodules.
In terms of liver cancer treatment, the new guidelines detail a variety of treatments commonly used today, including liver resection, liver transplantation, ablation therapy, endovascular intervention, radiation therapy, systemic anti-tumor therapy, traditional Chinese medicine therapy, etc. Liver resection is an important means for long-term survival of liver cancer patients. Based on the progress of surgical technology (including laparoscopic hepatectomy and robotic-assisted hepatectomy) and surgery-based comprehensive treatment strategies, it provides more possibilities for patients with advanced liver cancer to improve the surgical resection rate, reduce postoperative recurrence and metastasis, and improve prognosis for patients with advanced liver cancer. A moderate expansion of surgical indications has become a consensus.
Liver transplantation is one of the curative treatments for liver cancer, especially for patients with small liver cancer who are decompensated and not suitable for surgical resection and ablation. At this stage, this guideline recommends the UCSF standard, that is, a single tumor diameter ≤ 6.5 cm, the number of tumors ≤ 3, of which the largest tumor diameter ≤ 4.5 cm, and the total tumor diameter ≤ 8.0 cm, and no macrovascular invasion. Tumor recurrence and metastasis is the main problem after liver transplantation for liver cancer.
At present, ablation therapy has been considered as a curative treatment for small liver cancer in addition to surgical resection, and ablation therapy has the characteristics of less impact on liver function, less trauma and definite efficacy, and can obtain similar efficacy to surgical resection in some patients with early-stage liver cancer. Ablation treatment for liver cancer is a type of treatment method that directly kills tumor tissues by physical or chemical methods under the guidance of medical imaging technology.
Ablation treatments mainly include radiofrequency ablation (RFA), microwave ablation (MWA), absolute ethanol injection therapy (PEI), cryoablation (CRA), high-intensity ultrasound focused ablation (HIFU), laser ablation (LA), irreversible electroporation (IRE), etc. It is mainly suitable for early-stage liver cancer (i.e., single tumor, diameter ≤ 5cm; or 2~3 tumors with a maximum diameter of ≤3cm), a radical therapeutic effect can be obtained.
Transarterial intervention, usually referred to as "TACE", refers to the embolization of iodized oil emulsion or drug-loaded microspheres with chemotherapy drugs, supplemented by granular embolic agents (such as gelatin sponge particles, blank microspheres, polyvinyl alcohol particles) and other embolic agents through the arterial branch of the tumor. TACE combined with ablation therapy, radiotherapy, surgery, molecularly targeted drugs, immunotherapy and antiviral therapy is advocated to further improve the efficacy of TACE.
Radiation therapy is divided into external radiation therapy and internal radiation therapy. External beam radiation therapy uses radiation (photons or particles) generated by radiotherapy equipment to irradiate tumors from outside the body into the body. Internal radiation therapy uses radionuclides to be implanted into tumors through the body's tubes or through needle paths. Liver cancer is radiosensitive, and moderate doses of radiotherapy can achieve a better tumor remission rate.
Systemic therapy, or systemic therapy, mainly refers to anti-tumor therapy, including molecularly targeted drug therapy, immune checkpoint inhibitor therapy, chemotherapy and traditional Chinese medicine treatment. In addition, it also includes treatment for the underlying diseases of liver cancer, such as antiviral therapy, hepatoprotective and choleretic support, and symptomatic treatment.
Due to the insidious onset of liver cancer, less than 30% of liver cancer patients are suitable for radical treatment at the time of first diagnosis, and systemic anti-tumor therapy plays an important role in the treatment of advanced liver cancer. Systemic anti-tumor therapy can control the progression of the disease, prolong the survival time of patients, and some patients can achieve partial or complete tumor remission.
In the first-line systemic anti-tumor therapy, atezolizub monoclonal antibody combined with bevacizumb monoclonal antibody, sintilib monoclonal antibody combined with bevacizumab analogue and apatinib mesylate combined with camrelizumab monoclonal antibody were preferred, and the short-term and long-term efficacy was better than that of sorafenib monotherapy.
Traditional Chinese medicine (TCM) treatment is the characteristic and advantage of liver cancer treatment in mainland China. The new guidelines provide a phased treatment plan for early-stage liver cancer, middle-stage liver cancer, and end-stage liver cancer, as well as modern Chinese medicine preparations (acoladine, Huai'er granules, etc.).
Under the guidance of the clinical medicine system of integrated traditional Chinese and Western medicine for the differentiation and treatment of disease and syndrome, the clinical diagnosis and treatment mode of combining disease and syndrome is adopted for different stages of liver cancer, such as the early, middle and late stages, focusing on the core pathogenesis of liver cancer, "the rise and fall of cancer toxicity", comprehensively using Chinese medicine prescriptions, modern Chinese medicine preparations and traditional Chinese medicine characteristic diagnosis and treatment technologies, complementing and cooperating with modern medical technology, and forming a systematic and standardized program, in order to achieve synergistic anti-cancer, improve treatment tolerance, reduce postoperative complications, prevent recurrence and metastasis, It has the effect of alleviating adverse reactions and prolonging survival.
The treatment of liver cancer is characterized by multidisciplinary participation and the coexistence of multiple treatment methods, and each treatment method has its own unique advantages and limitations, and the indications overlap with each other. Therefore, the diagnosis and treatment of liver cancer must pay attention to the communication and cooperation of the multidisciplinary diagnosis and treatment team (MDT) to ensure that the most suitable treatment decision is selected for the patient and promote the continuous progress of liver cancer treatment technology.
3. Pay attention to MDT and work together to tackle tough problems
At present, the importance and necessity of MDT for HCC have become a broad consensus in the industry, but due to the influence of actual conditions, there are still great differences in the implementation and treatment level of MDT for HCC between different regions and different units. It is suggested that hospitals at all levels that carry out the diagnosis and treatment of liver cancer should incorporate MDT management into the medical quality management system, which should be jointly managed by the medical administrative department and the designated person in charge of MDT, and carried out in a multidisciplinary consultation mode with a fixed time, fixed place and fixed personnel.
Fourth, the authoritative guide, healthy peers
The publication and implementation of the Quality Control Indicators for Standardized Diagnosis and Treatment of Liver Cancer in China (2022 Edition) of the National Cancer Center will further promote the standardization and homogeneity of liver cancer diagnosis and treatment in China. The author saw that the experts of the editorial board of the new guide not only put a lot of effort into compiling a high-level guideline, but also held a number of large-scale high-level lecture tours in various places after the release, and continued to make efforts to promote and implement the new guideline, which is really commendable and indispensable!
I believe that under the guidance of this authoritative new guideline, the level of liver cancer diagnosis and treatment in mainland China will be raised to a new level, contributing to the goal of increasing the 5-year survival rate by 15% ahead of schedule, so that all liver cancer patients can benefit to the greatest extent.
As medical personnel engaged in the diagnosis and treatment of liver cancer, we should cherish this hard-won guideline, conscientiously study and practice the guideline, master new diagnosis and treatment techniques, and improve the ability to serve patients.
For high-risk groups of liver cancer, prevention should be taken first, and active screening should be carried out according to the requirements of the guidelines to prevent the disease before it occurs; In the unfortunate event of liver cancer, it can be detected early, diagnosed early, and treated early, and the most ideal results can be obtained in the new standardized treatment!
Source: Liver Cancer Online