肝癌合并门静脉癌栓现存分期的不足

Hepatocellular carcinoma with portal vein tumor thrombosis： deficiencies in the currently available classifications

国际上现有两种肝癌合并门静脉癌栓的分期标准，即中国的程氏分期和日本肝癌研究组的Vp分期。这两种分期区别不大。笔者较为推荐程氏分期，因为在影像学检查中日本Vp分期中的Vp1期和Vp2期较难分别，且日本Vp分期没有程氏Ⅳ期，而程氏Ⅳ期癌栓不可切除已无争议性。这两种分期的共同缺点为只考虑癌栓侵犯门静脉程度．而未考虑其他影响治疗和预后的因素。笔者借用巴塞罗那临床肝癌分期的优点，把以下影响肝癌合并门静脉癌栓治疗的重要因素加进程氏分期内：（1）病人整体情况、肝功能和伴有严重其他疾病。（2）肝外癌症转移。（3）门静脉主干癌栓。（4）肝癌可切除性。（5）微血管侵犯。笔者将肝癌合并门静脉癌栓分为：极早期（合并微血管侵犯），早期（肝癌可切除），中期（肝癌局部不可切除），晚期（伴肝外转移）和终末期（病人整体情况差、肝失代偿或伴其他严重疾病）。在早、中、晚期病人可再分为A期（程氏Ⅰ、Ⅱ期）或B期（门静脉主干癌栓）。每一种分期都有不同治疗方案和预后。然而，该新分期尚需要临床数据支持。

There are two international classifications for hepatocellular carcinoma with portal vein tumour thrombosis （HCC with PvTr） ： the Cheng＇s Classification and the Liver Cancer Study Group of Japan. These two classifications are quite similar. Personally I prefer the Cheng＇ s Classification for 2 reasons ： （ 1 ） it is not easy to differentiate Vpl and Vp2 in the Japanese Classification; and （2） the Japanese Classification does not have a stage for PVTT that extends to the superior mesenteric vein, i.e. the Cheng＇s Type IV. The main defect of these two classifications is that both classifications consider only the extent of PVTI＂ without considering other factors which impact on treatment and prognosis. I apply some important prognostic factors used in the Barcelona Clinic Liver Cancer （BCLC） Classification for liver cancer onto the Cheng＇s Classification of HCC with PVTT, to come up with a new Lau-Cheng Classification. These factors include ： （ 1 ） the general condition of the patient, the liver functional status and whether there is any serious associated medical diseases; （2） extrahepatic metastasis ; （3） main PVTT; （4） resectability of the primary liver cancer; （5） combination with microvascular invasion （MVI）. This new classification divides HCC with PVTT into the very early stage （ MVI only）, early stage （ resectable HCC with PVTT）, intermediate stage （not resectable）, late stage （with extrahepatic metasta- ses）, and terminal stage （ poor general condition, decompensated liver function, or associated with serious medical diseases）. The early, intermediate and late stages can further be divided into A and B according to whether the main portal vein is not involved or is involved by PVTT . All these different stages of HCC with PVTT have their own recommended treatment and prognosis. This new classification needs to be supported by clinical data before it can be used.