综合治疗时代肝癌外科手术治疗地位与时机变迁  

The evolution of the role and timing of surgical treatment in liver cancer in the era of comprehensive therapy

作　　者：杨宁 沈锋 YANG Ning;SHEN Feng(Department of Hepatic Surgery,Eastern Hepatobiliary Surgery Hospital,Naval Medical University,Shanghai 200438,China)

机构地区：[1]海军军医大学第三附属医院(东方肝胆外科医院),上海200438

出　　处：《中国实用外科杂志》2024年第9期1010-1015,共6页Chinese Journal of Practical Surgery

基　　金：上海市卫健委临床重点专科项目(No.shslczdzk02402);军队临床重点专科建设项目;上海市申康医院发展中心示范性研究型病房建设项目(No.SHDC2023CRW002);上海市申康医院发展中心肝癌专病队列数据质量提升项目(No.SHDC2024CRX023)。

摘　　要：在综合治疗时代,肝癌的治疗模式逐渐发生变化,外科手术的地位与时机也随之演变。肝癌的外科手术,特别是肝切除术和肝移植,始终是取得长期生存的重要手段。然而,随着靶向治疗和免疫治疗的引入及其与局部治疗手段的结合,肝癌的综合治疗体系不断完善,使得外科手术的时机和适应证发生了调整。转化治疗通过局部或系统治疗,使原本无法切除或不适合手术的肝癌病人达到手术标准,并显示出较好的长期生存优势。成功转化后序贯外科手术的病人比继续局部或系统治疗的病人具有更长的总生存期。此外,影像学完全缓解(rCR)或临床完全缓解(cCR)后,继续进行外科手术依然具有潜在价值。因此,在转化治疗成功后,评估肿瘤缓解程度,并适时进行手术切除,是优化肝癌治疗效果的关键。此外,术后辅助治疗的持续时间和最佳手术时机等问题仍需进一步的研究和高等级证据的支持。综合治疗的发展,特别是新辅助和辅助治疗策略的应用,使得肝癌治疗的多样性和复杂性进一步增加,这也对肝癌外科手术的地位提出了新的挑战。In the era of comprehensive treatment,the therapeutic strategy for hepatocellular carcinoma(HCC)has gradually evolved,leading to changes in the role and timing of surgical intervention.Surgical treatments for liver cancer,especially liver resection and liver transplantation,remain fundamental approaches for achieving long-term survival outcomes in patients with HCC.However,with the advent of targeted therapies and immunotherapies,combined with locoregional treatments,the comprehensive treatment framework for HCC has been refined,resulting in adjustments to the indications and timing for surgical procedures.Conversion therapy,which utilizes locoregional or systemic treatment to downstage tumors that were initially unresectable or unsuitable for surgery,has shown favorable long-term survival outcomes.Evidence suggests that patients who undergo subsequent surgical resection after successful conversion therapy exhibit superior overall survival(OS)compared to those who continue with locoregional or systemic therapies.Moreover,even in cases where radiological complete response(rCR)or clinical complete response(cCR)is achieved,surgical treatments still offer potential benefits.Therefore,evaluating tumor response after successful conversion therapy and performing timely surgical resection is crucial for optimizing treatment outcomes in HCC.Additionally,the optimal duration of postoperative adjuvant therapy and the precise timing of surgery remain areas that require further research and robust evidence.The advancement of comprehensive treatment,particularly through the implementation of neoadjuvant and adjuvant therapeutic strategies,has increased the complexity and diversity of HCC management,posing new challenges and opportunities for the role of surgical intervention in liver cancer.

关 键 词：肝细胞癌 外科手术 综合治疗 转化治疗 新辅助治疗 免疫治疗 靶向治疗 肝癌预后 

分 类 号：R6[医药卫生—外科学]