~Teachingcenter的醫學筆記~

肝臟手術Liver surgery
Decision making for surgical treatment of patient with hepatocellular carcinoma (Adapted from Makuuchi et al.)

決定是否肝臟手術或如何手術的因素，主要包含腹水(ascites)、血清膽色素(total serum bilirubin level)和ICG15。

Algorism: Ascites → Total Serum Bilirubin → ICG15

● Ascites:
  (1). not controllable → No surgery
  (2). Absent or Controllable → Total Serum Bilirubin
● Bilirubin:
  (1). >= 2.0 mg/dL → No surgery
  (2). 1.6 ~ 1.9 mg/dL → Enucleation
  (3). 1.1 ~ 1.5 mg/dL → Limited Resection
  (4). <= 1.0 mg/dL → ICG15
● ICG15:
  (1). <10% → Right (extended) hepatectomy, Left trisegmentectomy
  (2). 10 ~ 19% → Left hepatectomy, sectionectomy
  (3). 20 ~ 29 % → Segmentectomy
  (4). 30 ~ 39 % → Limited resection
  (5). >= 40% → Enucleation

ICG15可以參考
http://teachingcenter1.pixnet.net/blog/post/348697871
10％以下，可切除肝臟2/3  (接受各類肝葉切除)
10％~20%，可切除肝臟1/3  (左肝或右肝的單一小葉)
20％~30%，可切除肝臟1/6  (切除次小葉)
30％~40%，只可做部份切除  (<1/6，局部切除)
40％以上，只做核取出術  (也有人建議不應該手術)

Treatment approaches for hepatocellular carcinoma:
1) Potentially curative partial hepatectomy
= Solitary HCC confined to the liver that shows no radiographic evidence of invasion of the hepatic vasculature, no evidence of portal hypertension, and well-preserved hepatic function.
2) Liver transplantation - long waiting time for donor organs
= Solitary HCC < 5 cm in diameter or up to three separate lesions none of which is larger than 3 cm, no evidence of gross vascular invasion, and no regional nodal or distant metastases.
3) Radiofrequency ablation (RFA)
= Not meet resectability criteria for HCC; single tumor <4 cm in diameter.
4) Percutaneous ethanol or acetic acid ablation
= Ease and efficacy of RFA has supplanted its use in many institutions.
5) Transarterial chemoembolization (TACE)
= Eliminate the tumor's blood supply or to administer cytotoxic chemotherapy directly to the tumor.
= Lipiodol: promotes intratumoral retention of chemotherapy drugs.
= Simultaneous or sequential occlusion of the hepatic artery until stagnation of blood flow to the tumor occurs may result in greater antitumor efficacy than chemotherapy alone.
6) Cryoablation
= Unresectable HCC intraoperatively
= Abandoned cryotherapy in favor of RFA
7) Radiation therapy
= HCC is a radiosensitive tumor, but it is located in an extremely radiosensitive organ.
= As a whole, the liver can only tolerate about 20 Gy systemic chemotherapy.
= Difficulty with tumor localization
8) Systemic chemotherapy
= Cytotoxic chemotherapy
= Relatively chemotherapy refractory tumor-drug resistance genes
= Not well tolerated
= Less efficacy in patients with significant cirrhosis
= Molecularly targeted therapy: sorafenib

= Modest though statistically significant survival benefit for sorafenib (a multitargeted tyrosine kinase inhibitor) over supportive care alone in patients with advanced HCC.