巨大肝癌外科治疗探讨

目的：探讨巨大原发性肝癌的外科治疗。
方法：回顾性分析109例行手术切除治疗的巨大肝癌患者的临床资料。
结果：肿瘤最大径10.5~30(14.46±3.84)cm；病灶单发92例，多发17例；肿瘤位于左肝41例，右肝63例，超过半肝5例；83例合并肝炎后肝硬化，5 例肝癌破裂出血，19例合并门静脉癌栓(4例并有胆道癌栓)，15例有肝门或肝周腹腔淋巴结转移；术前肝功能Child A级101例， B级8例；98例AFP>500 μg/L，11例<20 μg/L；临床分期IIa期2例，IIb 期92例，IIIa期15例；规则切除42例，局限性肝切除67例，手术失血量400~2 200 mL；全组住院期无死亡，术后并发症82例次(75.23%)；68例获随访2~72个月，肝癌破裂出血5例切除术后生存8~13个月，63例非破裂肝癌择期手术切除后1，3，5年生存率分别为44.07%，13.06%和7.84%
结论：巨大肝癌切除近期效果优良，远期效果仍待提高；具备条件的巨大肝癌破裂出血可行一期切除。

Experience in surgical treatment of large primary liver cancer

Objective:  To explore the surgical treatment for large primary liver cancer.
Methods: The clinical data of 109 patients with large primary liver cancer undergoing hepatectomy were retrospectively reviewed.
Results: The maximum diameters of the tumors  ranged from 10.5 to 30 cm with the average of (14.46±3.84) cm, and 92 cases were single and 17 cases were multiple lesions. The tumor location was within the left lobe in 41 cases, right lobe in 63 cases and entended over half of the liver in 5 cases. Eighty-three cases were combined with posthepatitic cirrhosis, 5 cases complicated by rupture and bleeding of the liver cancer, 19 cases had tumor embolus of portal vein (4 cases with tumor embolus of bile duct) and 15 cases had metastasis to the hilar or juxta-hepatic  lymph nodes. The preoperative liver function grade was Child's grade A in 101 cases and grade B in 8 cases. The AFP levels of 98 cases were higher than 500 μg/L and in 11 cases were below 20 μg/L. Two cases were in clinical stage IIa, 92 cases in stage IIb and 15 cases in stage IIIa. Forty-two cases underwent anatomic liver resection and 67 cases underwent local resection, and the intraoperative blood loss was 400-2, 200 mL. No hospital death occurred, and the incidence of postoperative complications was 75.23%. Sixty-eight cases were followed up for 2 to 72 months, of whom the 5 cases with rupture and bleeding of the liver cancer survived for 8 to 13 months after surgery, and the 1-, 3-, and 5-year survival rate of the remaining 63 cases without tumor rupture was 44.07%, 13.06% and 7.84%, respectively after elective hepatectomy. 
Conclusion: Surgical treatment offers effective short-term in results patients with large primary liver cancer, but its long-term efficacy remains to be improved. One-stage resection may be feasible for ruptured large primary liver cancer in selected cases.