肝癌转化治疗中几个需要重视的问题

Several outstanding issues for conversion therapy of liver cancer

近年来,随着系统治疗和局部治疗的进步,肝细胞癌(下文简称肝癌)的诊疗理念正在发生深刻的变化。从原来“以手术为主”的“手术优先”理念,逐步转变为现在“以手术为基础”的“策略优先”理念。如何合理利用新型治疗手段围绕达到最优治疗效果来设计更为科学的治疗方案变得十分重要,肝癌转化治疗是其中重要的一环。通过综合治疗手段使初始外科学不可切除的肝癌病人获得手术切除机会,或者对初始可手术切除但预期疗效不佳的病人先行适当干预后实施手术以达到更好的肿瘤学效果。肝癌转化治疗是当前的研究热点,但是临床实施过程中仍面临一些有争议的问题:如何科学而个体化地筛选病人实施新辅助治疗?成功实现转化的肝癌病人是否必然需要手术?如何确定其手术时机以达到最佳疗效?如何在病人中合理使用肝动脉灌注化疗这一治疗手段以达到最优的转化效益?如何科学评价和使用促进剩余肝脏体积增生的治疗手段,如末梢门静脉栓塞或联合肝脏离断和门静脉结扎的二步肝切除术等等。此文作者结合自身经验就前述几个值得关注的问题进行了浅析。

In recent years,the advancements of systemic and local treatments have catalyzed transformations in the diagnostic and therapeutic paradigms for hepatocellular carcinoma.The traditional"surgery-first"philosophy of prioritizing surgery has gradually evolved into a"strategy-first"approach of treating surgery as a foundation.Various novel therapeutic approaches have been formulated for achieving optimal outcomes.And conversion therapy for liver cancer has played some vital roles in this evolution.This approach has opened up surgical opportunities for patients initially deemed unresectable with poor prognostic expectations.It involves preliminary preoperative interventions for better oncological outcomes.Conversion therapy of liver cancer is a hot research area.However,its clinical applications still have some contentious issues.For instance,how can we scientifically and individually tailor neoadjuvant therapy for patients?Is surgery always necessary for patients with a successful conversion?What is optimal operative timing for ensuring the best therapeutic outcome?How can hepatic artery infusion chemotherapy(HAIC)be judiciously utilized for maximizing the benefits of conversion?And how can we scientifically evaluate and employ treatments of promote the growth of future liver remnant(FLR),such as terminal branches portal vein embolization(TB-PVE)or associating liver partition and portal vein ligation for staged hepatectomy(ALPPS)?This review provided a preliminary discussion of these common concerns.