Primary liver cancer in the elderly
Introduction
Introduction to primary liver cancer in the elderly Primary carcinoma of the liver refers to a cancer that occurs in hepatocytes or intrahepatic cholangiocarcinoma. It is most common in hepatocellular carcinoma. Liver cancer is one of the most common malignancies in the world. China's liver cancer patients account for about 50% of the world. Its mortality rate is high, ranking third in the stomach and esophagus in the rank of malignant tumor death. In recent years, relying on serum alpha-fetoprotein (AFP) detection combined with ultrasound examination, liver cancer in the sub-clinical stage as a diagnosis, early surgical treatment combined with active comprehensive treatment, so that the 5-year survival rate is significantly improved. The onset of primary liver cancer is concealed, and the early symptoms are lacking. Most of the liver cancers are followed up or in the physical examination. AFP and B-mode ultrasound are used to detect liver cancer. The patient is asymptomatic and the physical examination lacks the signs of the tumor itself. It is called subclinical liver cancer. Once the symptoms appear, most of the patients have entered the middle and late stage. The most common clinical manifestations of advanced liver cancer are: upper abdominal mass or multinodular mass, liver pain, loss of appetite, Weight loss and fatigue, etc. basic knowledge The proportion of patients: the incidence of hepatitis B patients is about 5% Susceptible people: the elderly Mode of infection: non-infectious Complications: hepatic encephalopathy, gastrointestinal bleeding, ascites, pneumonia
Cause
The cause of primary liver cancer in the elderly
Viral hepatitis (30%):
The study found that hepatitis B virus is closely related to liver cancer and is an important risk factor for liver cancer. 1 The serum of hepatitis C patients has more than 90% of hepatitis B markers; 2 HBsAg-positive people with high incidence of liver cancer have higher chance of liver cancer than negative ones. ~50 times; 3 molecular biology studies show that the simple integrated HBV-DNA accounted for 51.5% in China's liver cancer patients; 4HBV X gene can change the gene expression of HBV-infected hepatocytes and cancer may be related, hepatitis B virus causes liver Cell damage is followed by hyperplasia or dysplasia, which is sensitive to carcinogens. There may be multiple genes in multiple pathogenesis and multi-stage pathogenesis, ie a group of protooncogenes are activated as oncogenes, and 1 or Inactivation of multiple anti-cancer genes causes uncontrolled cell growth, proliferates, and causes cancer. Hepatitis C virus infection is also associated with liver cancer.
Aspergillus flavus virus (15%):
Animal experiments have shown that corn and peanut contaminated by Aspergillus flavus can cause liver cancer, which is due to the strong carcinogenic effect of aflatoxin, aflatoxin B1. Epidemiological investigation found that the grain is contaminated with aflatoxin B1. In severe areas, the incidence of liver cancer is also high, suggesting that aflatoxin may be the cause of high incidence of liver cancer in some areas.
Cirrhosis of the liver (25%):
About 50% of patients with primary liver cancer complicated with cirrhosis, pathological examination found that liver cancer combined with cirrhosis is mostly massive nodular cirrhosis after hepatitis B.
Drinking water pollution (10%):
Qidong reported that the incidence of liver cancer in drinking water ponds was significantly higher than that in drinking wells. The investigation found that blue-green algae growing in ponds are strong carcinogenic plants, and liver cancer is related to this.
Genetic factors (10%):
In the high incidence area of liver cancer, family aggregation sometimes occurs, especially in patients with common life and blood relationship, the prevalence of liver cancer is high, which may be related to the vertical transmission of hepatitis virus.
Other (5%):
Trace elements, Chinese branch testosterone, alcohol, etc., found in water, soil, food, human hair and blood contain high levels of copper, zinc, low molybdenum, Chinese branch of testicular trematode can stimulate bile duct epithelial hyperplasia Produces cholangiocarcinoma.
Pathogenesis
4/5 of primary liver cancer is hepatocellular carcinoma, and 1/5 is cholangiocarcinoma.
1. Classification
(1) Gross shape classification:
1 block type: the most common, the diameter of the cancer block is more than 5cm, larger than 10cm, called giant block, can be single, multiple or fused into a block, mostly round, hard, expansive growth, the edge of the mass may have Small satellite stoves, such cancerous tissue is prone to necrosis, causing liver rupture.
2 nodular type: for the size and number of cancer nodules, the general diameter is not more than 5cm, the nodules are mostly in the right lobe of the liver, and the boundary between the surrounding tissues is not as clear as the giant block type, often accompanied by cirrhosis, this type Can be divided into single nodules, multiple nodules and fusion nodules three subtypes.
3 diffuse type: cancer nodules are small, there are cancer nodules of rice size to soybean size scattered throughout the liver, the naked eye is not easy to distinguish from cirrhosis, liver is not obvious, or even can be reduced, patients often die of liver failure, this type See you at least.
4 small cancer type: isolated cancer nodules less than 3cm in diameter or the sum of the diameters of two adjacent cancer nodules less than 3cm is called small liver cancer, the patient has no clinical symptoms, but serum AFP is positive, AFP drops to normal after tumor resection .
(2) Cell typing:
1 Hepatocyte type: the most common, the main feature is that cancer cells are similar to normal cells, but the cell size is different. The cancer cells are developed from liver cells. This type accounts for about 90% of liver cancer. The cancer cells are polygonal and nuclear. The nucleolus is obvious, the cytoplasm is abundant, the cancer cells are arranged in a nest or cord, and there are abundant sinusoids between the cancer nests. The cancer cells have a tendency to grow into the sinusoids. Fibrolamellar carcinoma is a type of liver that has recently received attention. Cellular cancer, which has lamellar fibers surrounding the cancer nest, has a high rate of surgical resection, with more young people, and the prognosis is better than that of ordinary liver cancer.
2 biliary cell type: developed from biliary cells, this type is rare, cancer cells are cuboidal or columnar, arranged into glands, more fibrous tissue, less sinusoids.
3 mixed type: the above two types exist at the same time, or in a transitional form, neither completely like liver cells, nor completely like bile duct cells, this type is less common.
2. Transfer route
(1) Blood transfer:
1 intrahepatic metastasis: intrahepatic hematogenous metastasis occurs at the earliest and most common, can invade the portal vein branch to form a tumor thrombus, tumor thrombosis after the fall causes multiple metastases in the liver, such as the portal vein of the dry branch with tumor thrombus obstruction, can cause portal hypertension And intractable ascites,
2 In the extrahepatic metastasis, the highest rate of lung metastasis, after the tumor is formed in the hepatic vein, can extend up to the inferior vena cava, even to the right heart chamber, or a small tumor thrombus falls into the pulmonary artery and causes pulmonary embolism to form. Metastasis, blood transfer can also involve the adrenal gland, bone, kidney, brain and other organs.
(2) lymphatic metastasis: local metastasis to the hilar lymph nodes, but also to the para-aortic lymph nodes, supraclavicular lymph nodes, pancreas, spleen.
(3) implant transfer: rare, cancer cells falling off the liver can be planted in the peritoneum, sputum, chest and other places cause bloody ascites, pleural effusion, such as planted in the pelvic cavity, can form a large lump in the ovary.
3. Liver cancer classification Currently commonly used is the Edmondson grade 4 classification method:
Grade I: For high differentiation, the morphology of liver cancer cells is similar to that of normal liver cells.
Grade II: The morphology of liver cancer cells is close to that of normal liver cells, but there are mild abnormalities, the proportion of nucleoplasm is increased, nuclear division is increased, and the structure of acinus is common, and bile is visible.
Grade III: Liver cancer cells have obvious abnormalities, large and irregular nuclei, and the proportion of nucleoplasm is significantly increased. Giant cells are more common and bile is less.
Grade IV: The morphology of cancer cells is very variable. There are often many spindle cells, with less cytoplasm, a significantly increased nucleoplasm ratio, no obvious nucleoli, disordered cell arrangement, and no specific structure.
Prevention
Primary liver cancer prevention in the elderly
High-risk groups of liver cancer include:
HBsAg positive over 140 years old;
2 have a history of hepatitis or cirrhosis;
3 family history of liver cancer, >30 years old, regular follow-up observation of high-risk groups of liver cancer, can be found in many early liver cancer patients, subclinical (or small liver cancer) liver cancer discovery pathways are:
1 AFP (or B-ultrasound) survey in the general population;
2 Tracking of high-risk groups, regularly using AFP (or B-ultrasound) testing;
3 patients with occasional discomfort and inspection found;
4 other tests or surgery (such as splenectomy) are occasionally found.
Active prevention and treatment of viral hepatitis, cirrhosis: pay attention to food, drinking water sanitation, preserve good food, prevent mildew, protect water sources, prevent pollution is the current measures to be taken, use viral hepatitis vaccine (type B or C) to prevent hepatitis, It also plays a role in the prevention of primary liver cancer. Early detection, early diagnosis and early treatment of liver cancer are called "secondary prevention" in oncology. Since the use of alpha-fetoprotein in the 1970s for liver cancer screening in China The diagnosis of primary liver cancer has entered the subclinical level. The proportion of early liver cancer is increasing, and the 5-year survival rate is also significantly improved. Since the 1980s, the detection rate of high-risk population surveys is 34.3 times that of natural population. One third of them are early liver cancer. Highly sensitive alpha-fetoprotein detection method, one to two ultrasound examinations per year is the basic method for early liver cancer detection. The combined detection rate of the two can reach 97.9%. For early detection of small liver cancer, surgical resection should be taken as actively as possible in order to achieve the goal of radical cure. The 5-year survival rate of small hepatocellular carcinoma after radical resection is about 70%. Surgical treatment of multiple deaths within 2 years.
Complication
Elderly patients with primary liver cancer complications Complications, hepatic encephalopathy, digestive tract bleeding, ascites pneumonia
1. Hepatic encephalopathy: Often a terminal complication of liver cancer, about one-third of patients die.
2. Gastrointestinal hemorrhage: Hemorrhage accounts for about 15% of the cause of liver cancer death. Hepatocellular carcinoma often has cirrhosis or portal vein. Hepatic vein tumor thrombosis may cause esophageal or gastric varices bleeding due to portal hypertension. Mucous membrane erosion, blood clotting mechanism and other bleeding.
3. Hepatocellular nodule rupture and hemorrhage: The incidence rate is about 10%, the liver cancer tissue is enlarged, necrosis or liquefaction can cause spontaneous rupture, or it can be broken due to external force. If the rupture is limited to the capsule, there may be local severe pain, such as Submucosal hemorrhage rapidly increases to form a tender mass, can also break into the abdominal cavity to cause acute abdominal pain and peritoneal irritation, a large number of bleeding leading to shock and death, small rupture bleeding is characterized by bloody ascites.
4. Bloody chest and ascites: Liver cancer can directly infiltrate or cause bloody chest and ascites by blood flow or lymphatic metastasis. The pleural effusion is common on the right side.
Secondary infection: due to long-term consumption of cancer, reduced resistance, or reduced blood cells due to radiochemical treatment, weakened resistance, plus long-term bed rest and other factors, easy to concurrent with various infections, such as pneumonia, intestinal infection , fungal infections, etc.
Symptom
Symptoms of primary liver cancer in the elderly Common symptoms Loss of appetite, alpha-fetoprotein, increased appetite, indigestion, liver function, abnormal lymph node enlargement, weight loss, weight loss, liver palm
1. Symptoms of primary liver cancer are insidious, early lack of typical symptoms, and more often in the follow-up of liver disease or physical examination, AFP and B-mode ultrasound examination of liver cancer, the patient is asymptomatic, physical examination and lack of the tumor itself Signs, this period is called subclinical liver cancer. Once the symptoms appear, most of the patients have entered the middle and late stage. The most common clinical manifestations of advanced liver cancer are: upper abdominal mass or multinodular mass, liver area pain, Loss of appetite, weight loss and fatigue.
(1) Pain in the liver area: the most common, mostly persistent swelling or dull pain, liver pain is caused by rapid tumor growth, the liver capsule is pulled, such as lesions invading sputum, pain can involve the right shoulder, right Post-growth tumors can cause pain in the right side. If the tumor grows slowly, it can be completely painless or only slightly dull. When the cancerous nodules on the surface of the liver rupture, the necrotic cancer tissue and blood flow into the abdominal cavity, it can suddenly cause drama. Pain, from the liver area to the full abdomen, the performance of acute abdomen, such as large amount of bleeding, causing fainting and shock, peritoneal cancer metastasis, there may also be peritoneal irritation, but the pain is more moderate.
(2) digestive tract symptoms: manifested as loss of appetite, indigestion, nausea, vomiting and diarrhea, bloating or constipation, loss of appetite and abdominal distension, lack of specificity, gastrointestinal symptoms of patients with chronic liver disease progressively worsened and difficult to relieve The possibility of liver cancer should be highly suspected and further examination is needed.
(3) systemic symptoms: manifested as fatigue, weight loss, systemic failure, advanced patients may be cachectic.
(4) fever: generally low fever, even up to 39 ° C, fever is related to the absorption of cancer necrosis products, cancer compression or invasion of the bile duct can be complicated by biliary infection and cause fever.
(5) metastases symptoms: tumor metastasis has corresponding symptoms, sometimes become the initial symptoms of the discovery of liver tumors, such as metastasis to the lungs can cause cough, hemoptysis, transfer to the pleura can cause chest pain and bloody pleural effusion, tumor thrombus embolization of the pulmonary artery or Branches can cause pulmonary infarction, which is characterized by sudden severe dyspnea and chest pain. Metastasis to bone can be manifested as bone pain, most often involving vertebrae, ribs, long bones of the extremities (especially the femur), skull and clavicle, which can cause pathological fractures. Vertebrae metastasis is particularly serious, can cause hemiplegia or nerve root compression, when the tumor thrombus obstructs the inferior vena cava, there may be lower extremity edema, obstruction of the hepatic vein can cause Budd-chiari syndrome, manifested as tension ascites, diffuse enlargement of the liver and Tenderness, intracranial metastases can have corresponding symptoms and signs.
(6) The special clinical manifestations of primary liver cancer: the abnormality of the cancer itself or the endocrine or metabolic syndrome caused by various effects on the body of the cancer is called cancer syndrome, and sometimes it may precede the symptoms of liver cancer itself. appear.
Cancer syndrome is mainly manifested in metabolism, endocrine and blood system:
1 erythrocytosis: is a common carcinogenesis phenomenon, about 2% to 10%, more common in men, usually no clinical symptoms, red blood cells are higher than normal during the test, the pathogenesis is not completely clear, some patients in serum erythropoietin There are several possibilities for increased activity:
A. Liver cancer cells can produce substances having erythropoietin-like activity.
B. Tumor tissue secretes a large amount of globulin, which reacts with erythropoiesis secreted by the kidneys to produce excess erythropoietin.
C. Liver tissue adjacent to liver cancer Due to rapid tumor growth, insufficient oxygen supply may occur, and the kidney may be stimulated to secrete erythropoietin or erythropoiesis stimulating factor.
D. Liver's inactivation of erythropoietin, advanced cirrhosis often has varying degrees of anemia, erythrocytosis in patients with cirrhosis is a reliable indicator of canceration. In recent years, with the improvement of the diagnosis of liver cancer, it is further proved that erythrocytosis can be Liver cancer appears early and changes with treatment. Red blood cells can be normal after surgical resection of liver cancer.
2 hypoglycemia: more common, the incidence of about 10% to 30%, is the most dangerous with cancer syndrome, the reason is that hepatocytes can ectopically secrete insulin or insulin-like substances; or tumor inhibits insulinase secretion of an islet B cell stimulating factor or glycogen storage is too much; can also be caused by excessive consumption of glucose in liver cancer tissue, patients often have hunger, blood sugar can be lower than 1.65mmol / L, severe cases of coma, shock, it is necessary for liver cancer patients Regularly check blood sugar for treatment, clinical hypoglycemia coma needs to be differentiated from hepatic encephalopathy.
3 hypercalcemia: the mechanism of occurrence and liver cancer tissue secretion of hormones or hormone-like substances affecting blood calcium metabolism, patients often have long-term nausea, reduced sputum reflexes, more urine, drowsiness, mental disorders, coma, etc., the application of corticosteroids Reduce blood calcium, when blood calcium is increased to 3.8mmol / L, should reduce blood calcium in time, otherwise it is life-threatening.
4 hypercholesterolemia: the pathogenesis of liver cancer with hypercholesterolemia may be due to the lack of a normal negative feedback system in cancer cells, so cholesterol synthesis increases, in addition, due to the lack of corresponding receptors on the liver cancer cell membrane, chylomicrons can not Caused by a deficiency in the ability to bind cholesterol in hepatocytes or liver cancer cells.
5 thrombocytopenia: may be related to the increase of thrombopoietin in liver cancer, after the tumor is resected, the number of platelets can return to normal.
6 hyperthyroidism: clinical manifestations of anxiety, both hands tremor and tachycardia, serum TSH, T3, T4, free T4 increased significantly, and increased with the progress of the disease, the mechanism of which is the tumor produces an ectopic TRH substance, The latter stimulates pituitary synthesis and release of TSH.
7 other: hypertrophic osteoarthrosis, sexual signs change, skin gonorrhea, abnormal fibrinogenemia, increased calcitonin, leukemia-like reaction, polymyositis.
All of the above manifestations in the resection or reduction of liver cancer can return to normal or decline.
2. The typical signs of liver cancer are liver, splenomegaly, jaundice and ascites.
(1) Liver enlargement: Progressive hepatomegaly is one of the most common characteristic signs. The liver is hard and the surface is uneven. There are nodules or large blocks of different sizes. The edges are blunt and not uniform, often with varying degrees. Tenderness, when the liver cancer is located under the right rib arch or under the xiphoid process, the upper abdomen is locally uplifted or full. The cancer is located on the face of the face. The main manifestation is that the sacral elevation is high and the lower edge of the liver is small. The most common cancer nodules under the rib arch are Easy to be touched.
(2) Astragalus: generally appear in the late stage, the reasons are mostly: 1 extensive damage of liver cells; 2 cancer compression or invasion of the bile duct near the hepatic hilum; 3 cancer tissue and blood clots fall off caused by biliary obstruction.
(3) signs of cirrhosis: elderly patients with liver cancer combined with cirrhosis, may have spider mites, liver palm, male breast development, testicular atrophy, splenomegaly, ascites, venous collateral circulation and other phenomena.
(4) Ascites: grass yellow, blood color, blood ascites mostly caused by cancer invasion of the liver capsule or ulceration into the abdominal cavity, caused by peritoneal metastasis.
(5) Hepatic vascular murmur: due to tumor compression of the large blood vessels in the liver or the tumor itself is rich in blood vessels.
(6) Hepatic area friction sound: It is audible on the surface of the liver area, suggesting that the liver capsule is invaded by the tumor.
(7) corresponding signs of metastases: there may be supraclavicular lymph nodes, pleural metastases may appear pleural effusion or hemothorax, bone metastases can be seen outwardly protruding from the bone surface, sometimes pathological fractures can occur, spinal cord metastasis compression spinal nerve can be expressed Paraplegia, intracranial metastases may have neuropathological signs such as hemiplegia.
Examine
Examination of primary liver cancer in the elderly
Detection of tumor markers : Tumor markers are substances produced and released by cancer cells. They are often present in tumor cells or in host fluids in the form of antigens, enzymes, hormones, and metabolites. They can be identified based on their biochemical or immunological properties. Or diagnose a tumor.
1. Alpha-fetoprotein (AFP) is the main indicator and the most specific marker for the diagnosis of liver cancer. AFP is an embryonic protein synthesized by the liver during fetal period. It is composed of fetal liver cells and rough endoplasmic reticulum ribose in yolk sac cells. The particles are synthesized, and the embryos are synthesized in the early stage (about 14 weeks), peaking at 20 weeks, and then descending sharply. After 1 to 2 weeks after birth, they disappear or only traces <20 g/L, which cannot be detected by conventional methods. High concentrations of AFP appear in serum, suggesting hepatocellular carcinoma or gonad embryonal tumor, in children suggest hepatoblastoma or hepatocellular carcinoma, a small number of stomach, pancreas, bile duct, colorectal cancer AFP can also be elevated, but its absolute The value is not as high as liver cancer, chronic hepatitis, cirrhosis may have molecular variants of AFP. Therefore, serum AFP test results must be combined with clinical and B-ultrasound, CT and other examinations have diagnostic significance.
AFP is a tumor marker with strong specificity and high sensitivity in liver cancer. It has been widely used in the screening, diagnosis, judgment and treatment of hepatocellular carcinoma, and predicts recurrence. The positive findings of census can be 8 to 11 months earlier than the symptoms. Multi-purpose radioimmunoassay (RIA) or AFP monoclonal antibody enzyme immunoassay (EIA) rapid assay, the two methods are sensitive, accurate, convenient, suitable for general survey.
The criteria for clinical diagnosis of hepatocellular carcinoma by AFP are:
1AFP is greater than 500g/L for 4 weeks;
2AFP gradually rises from a low concentration;
3AFP is moderately above 200g/L for 8 weeks, and other diseases that can cause elevated AFP, such as pregnancy and reproductive embryonal tumors, can be diagnosed by combining with localization examination.
Usually, the concentration of AFP is related to tumor size, but the individual is quite different. It is generally considered that the pathological differentiation is close to normal hepatocytes or the degree of differentiation is very low. AFP is often low or undetectable. Clinically, it can be divided into small according to the size of hepatocellular carcinoma. Liver cancer (2cm), small liver cancer (3~5cm) and large liver cancer (>5cm). Generally speaking, the concentration of serum AFP can reflect the size and growth rate of liver cancer. It is reported that the positive rate of AFP in liver cancer <3cm is only 25%. ~50%, 4cm AFP up to 400g / L or more, 5cm often rise to 700 ~ 1000g / L, but the tumor size is not always related to serum AFP levels, even small liver cancer may produce high concentrations of AFP, and Some giant liver cancers do not necessarily have high AFP, which is related to the incidence of liver cancer secreting AFP and its biological characteristics. About 10% of liver cancers do not produce AFP, and 30% of liver cancers produce little AFP. .
The serum AFP concentration can be used to check the high-risk population of liver cancer. The serum AFP is detected more than 3 times for 2 consecutive months, the content is between 50-200g/L, and the AFP low-positive concentration is positive. The census found in the high-incidence area of liver cancer, low-holding Yang has more chronic hepatitis and cirrhosis. In Qidong, China, 3177 cases of AFP low-sustained patients were followed up. The incidence of liver cancer was 10.46% in one year, which was 315.2 times that of the local natural population. It can be seen that AFP is a group of liver cancer. High-risk groups, some of which are subclinical liver cancer, therefore, AFP is measured every few months for HCC high-risk groups. When the AFP value continues to increase, even if it is slightly increased, further imaging studies are needed. AFP can also be used to assess surgery or other effects, and to judge prognosis. In chronic active liver disease, serum AFP can also be elevated, which is caused by hepatocyte repair and regeneration. Dynamic observation of serum AFP and ALT can help with liver cancer. Identification, such as the dynamic curve of the two equal or synchronized, or ALT continues to rise to a normal multiple, the duration is not long, with the recovery of ALT, AFP also decreased to normal, then active liver disease can Large; as two separate curves, the ALT returned to normal or decreased, not only of AFP is not decreased, but increased significantly, the plurality of HCC.
In recent years, domestic and foreign scholars have studied AFP heterogeneity and found that AFP produced by liver cancer and metastatic liver cancer, embryonic cell tumor and benign active liver disease have different sugar chain structure, ie, different degree of fucosylation, liver cancer The activity of fucose chymase in the serum of patients is significantly increased, the degree of AFP fucosylation is high, AFP fucosylation is different, and they exhibit different affinities when reacting with plant lectins, thus different AFP heterogeneity, using affinity electrophoresis or affinity chromatography to separate human serum AFP into lentil lectin (ICA) or concanavalin A (ConA) binding and non-binding, benign liver disease and umbilical cord serum Most of the AFPs are non-binding parts of lentils, while the proportion of non-binding parts of AFP produced by liver cancer is lower, and the binding parts are increased to varying degrees. In yolk sac tumors and metastatic liver cancer, AFP is mainly In combination, in the serum of patients with liver cancer, the proportion of AFP that can bind to ConA is higher (usually 50% or higher). Thus, LCA binding assay can be used to identify benign liver disease and liver cancer, and ConA binding test can be used to identify Primary liver Cancer and metastatic liver cancer, according to the ratio of two types of heterogeneous body can identify benign and malignant liver disease, the diagnosis rate of liver disease is 87.2%, and the diagnosis is not affected by AFP concentration, tumor size and disease period.
AFP monoclonal antibodies, using a monoclonal antibody against LCA-binding AFP to establish a specific, sensitive method, or labeling antibodies with nuclide, help identify the location of liver cancer and benign liver disease.
2.r-glutamyltransferase (r-GT) , which is high in the fetal period of r-GT and rapidly decreased after birth, is also called carcinoembryonic enzyme, whether in the precancerous stage or the stage of liver cancer formation, in the liver cells. -GT value is significantly increased, therefore; determination of blood r-GT can be used as one of the basis for early diagnosis of liver cancer, but biliary obstruction, biliary tract cancer and metastatic liver cancer patients can also increase blood r-GT, so r-GT for liver cancer Lack of specificity. In recent years, r-GT can be divided into 11 to 13 bands by polyacrylamide gel gradient electrophoresis. Among them, liver cancer is specific to II, II and I bands, of which r-GT2 is The positive rate of primary and metastatic liver cancer can be mentioned as 90%, the specificity is 97.1%, the false positive rate of non-cancerous liver disease and extrahepatic disease is less than 5%, r-GT2 is not related to AFP, and low-concentration AFP liver cancer and In the false-negative liver cancer, there was also a high positive rate, and the positive rate of small liver cancer r-GT2 was 78.6%.
3. Abnormal prothrombin (AP) , liver-producing prothrombin inactive precursor, carboxylated into active form by vitamin Kr, liver cancer, microparticles in vivo, vitamin K-dependent carboxylate dysfunction, carboxylation Decreased enzyme activity leads to incomplete glutamate carboxylation, which forms abnormal prothrombin. The liver cancer cells themselves have the function of synthesizing and releasing abnormal prothrombin. The AP is determined by radioimmunoassay and is positive by 250g/L. The positive rate of patients is 67%, while benign liver disease and metastatic liver cancer are only a few positive, so it has early diagnostic value for subclinical liver cancer.
4. Serum fucosidase (AFu ) AFu is a lysosomal acid hydrolase. The main physiological function is to participate in the catabolism of fucose-containing glycoproteins, glycolipids and other biologically active macromolecules. AFu should exceed 110nKat/L. Considering primary liver cancer, the sensitivity of diagnosis of primary liver cancer is 75%, the specificity is 90%, and the positive for AFP-negative liver cancer and small liver cancer is more than 70%. Secondary liver cancer and benign liver occupying lesions are negative, but Liver cirrhosis, chronic hepatitis has a higher false positive.
5. 1- antitrypsin (AAT) liver cancer cells have the function of synthesizing and secreting AAT, which is elevated when the tumor is combined with cell necrosis and inflammation.
6. Alkaline phosphatase isoenzyme I (ALP-I) ALP-I is a carcinoembryonic protein produced by liver cancer cells, almost exclusively found in hepatocellular carcinoma, with strong specificity but low positive rate.
7. Serum ferritin and acidic isoferritin (HIF) The liver is rich in ferritin, which is also the main site for the elimination of ferritin in the circulation. During liver disease, ferritin escapes from damaged liver cells, and the liver itself processes ferritin. The ability to decrease, resulting in elevated serum ferritin concentration, isoformin in liver cancer due to increased synthesis of liver cancer cells, the release rate is accelerated, it has a certain significance for the diagnosis of liver cancer, some scholars believe that serum ferritin is moderately sensitive to liver cancer Specificity, its specificity is lower than AFP, but it is diagnostic for AFP-negative patients. If AFP and ferritin are negative in patients with cirrhosis, the possibility of combining liver cancer is very small, and ferritin is elevated, often found low. AFP content, HBsAg-negative, small liver cancer in patients with alcohol abuse history, liver cirrhosis and other diseases, serum ferritin can be elevated, but often accompanied by elevated serum iron and transaminase, can be identified, so simultaneous determination of AFP and serum Ferritin is a valuable method for detecting liver cancer in cirrhosis in high-risk populations.
8. Aldolase isoenzyme A (ALD-A) aldolase isoenzymes have three forms of A, B, C, type A mainly exists in muscle and fetal liver tissue, and normal liver tissue is mainly type B. When hepatocytes become cancerous, ALD-A reappears and gradually replaces ALD-B. The positive rate of hepatocellular carcinoma ALD-A is 76%, and the differentiation of hepatocellular carcinoma is worse. The stronger the AID-A positive reaction, the surgical removal of tumor After embolization treatment, the concentration of ALD-A decreased, and the positive rate of AFP-negative liver cancer was >70%.
9.M2-pyruvate kinase (M2-PyK) : Pyruvate kinase (PyK) is a key enzyme in glycolysis, with four isoenzymes of L, R, M1 and M2, mainly in fetal liver and liver cancer tissues. It is M2 type, which can be regarded as a kind of carcinoembryonic protein. The ELISA sandwich method can detect the cancer marker with high sensitivity of Pg level. It is obviously increased in the stage of small liver cancer. The worse the differentiation, the more obvious the increase of M2-PyK value, the digestive tract Tumors can also be elevated, while hepatitis, benign liver tumors are not high.
The above liver cancer markers are important for the diagnosis of primary liver cancer. According to practical experience, combined detection is superior to single detection. Serum AFP detection combined with 1 or 2 liver cancer markers can significantly improve the positive detection of primary liver cancer. Rate, clinical analysis should be combined with medical history, imaging diagnostics or histological data to determine the exact conclusion.
10. Ultrasound imaging
Ultrasound advantages:
1 simple;
2 no trauma to the human body;
3 can be checked repeatedly;
4 low cost;
5 sensitivity to soft tissue organ lesions is high, ultrasound can be ranked as the first choice for the examination of focal lesions, the diagnosis rate of hepatocellular carcinoma can reach 90%, the ultrasound characteristics of hepatocellular carcinoma can be due to the size of the tumor, the growth rate Different, tumors less than 2cm in diameter are common hypoechoic nodule type, 2 ~ 3cm people show low echo and surrounding low echo frequency, 3 ~ 5cm are mostly low echo, and more than 5cm are high echo or mixed Echo, slow-growing hepatocellular carcinoma, often showing hypoechoic type; hepatic hepatocellular carcinoma with faster growth, mostly low echo type around; medium growth rate is both.
Hepatocellular carcinoma has the following characteristics:
1 Halo: Has a clear tumor capsule, the center of the nodule is relatively uniform and high echo and the adjacent capsule is a hypoechoic dark ring, which is a "sound", which is or is interpreted as a blood vessel around the tumor.
2 nodules in the nodules: nodules with different echoes in the hyperechoic tumor area, suggesting a new tumor foci growing in hepatocellular carcinoma.
3 intratumoral septum: that is, a thin, non-echoic septum or linear structure can be seen in liver cancer, which is consistent with the formation of the capsule type liver cancer, and the reaction liver cancer has the characteristics of producing fibers.
4 strong echo: small tumors, small liver cancer can be expressed as a uniform strong echo mass, which is the result of diffuse steatosis of cancer tissue.
B-ultrasound imaging of liver cancer should be differentiated from metastatic liver cancer and hepatic hemangioma.
1 metastatic liver cancer: mostly multiple nodules, single lesions and diffuse type are rare, nodular morphology is often irregular, showing a surrounding low echo type or strong echo type or mixed echo type, visible cluster sign, that is, many small The echogenic nodules cluster or merge into a large tumor, or a central anechoic zone, that is, a circular anechoic zone in the center of the strong echo zone, which is caused by central liquefaction necrosis of metastatic cancer.
2 hepatic hemangioma: the most common type of strong echo, characterized by dense echogenic light group and clear boundary with surrounding liver parenchyma. Color Doppler can distinguish the relationship between blood flow and mass. Diagnosis provides a better way.
Ultrasound imaging can not only locate liver cancer, but also show whether there is a tumor thrombus in the main stem and its branches, to understand the anatomical relationship between the mass and the large blood vessels, whether there is cancer spread and intra-abdominal lymphatic metastasis, to determine before surgery Treatment options, estimation of the possibility of resection and selection of indications for hepatic artery embolization and postoperative monitoring of recurrence have important value.
The main deficiency of ultrasound imaging is that the lesions in the right hepatic lobe and hepatic hilum are easily missed. The diagnostic accuracy and sensitivity depend to a large extent on the experience of the examiner and the sensitivity of the instrument.
11. Computerized tomography (CT) CT has the advantages of clear image, high resolution, non-invasive examination, etc. After injection of contrast agent, it can enhance tissue contrast and improve the detection rate of liver cancer. In various imaging examinations, CT can best reflect the pathological manifestations of the liver, such as the size, shape, location, number of lesions, whether there is intralesional bleeding, necrosis and the presence or absence of tumor thrombus in the portal vein, and the invasiveness of the lesion. CT is the preferred non-invasive diagnostic method.
CT findings of liver cancer:
(1) Plain scan performance: the lesion is generally low density, lower than the surrounding liver parenchyma density, and some lesions have a lower density of ring shadows (halo sign), the nodular edge is clear, massive and mixed The edges are mostly blurred or partially clear. Larger liver cancers, such as cancerous tissue necrosis, show low density and unevenness. Round or oval nodules with low-density halos suggest a thick envelope, but Liver cancer can be equal density if it is a diffuse small nodule type. It is generally considered that CT scan is difficult to identify lesions less than 2cm in diameter, which may cause misdiagnosis and missed diagnosis. For liver cancer less than 3cm, the positive rate of CT is about 60%.
(2) Enhanced performance: After the intravenous injection of iodine contrast agent, the density of lesions and liver tissue were improved to varying degrees, which is said to be enhanced, including:
1 Dynamic enhanced scanning: dynamic scanning early enhancement map is easy to find satellite lesions with a diameter less than 1cm or 1~2cm, which also contribute to the discovery of small lesions.
2 non-dynamic scanning: ordinary scanning at least 15s each time, so the liver level of the lesion may fall in any phase of the above dynamic scanning and have different densities, and most of the lesions fall in the low-density period, so the lesions are more flat. Significantly reduced CT findings of portal system and other systems: The rate of tumor thrombosis in the portal vein system of primary liver cancer is higher. If there is a tumor thrombus, the liver density of the leaf is reduced, and the enhanced tumor thrombus is obvious. Intensive blood-to-blood differences are large, showing strip filling defects leading to irregular or non-developed portal veins or branch vessels. A small number of patients have inferior vena cava tumor thrombus formation, hepatic hilar invasion can cause intrahepatic bile duct dilatation, and occasionally retroperitoneal lymph nodes Swelling, ascites, etc., iodized oil CT is a characteristic of the use of lipiodol in the cancer nodules of multiple arterial vessels. After hepatic artery angiography, iodized oil is injected, and CT scan is performed 1 to 2 weeks later.
Because normal liver tissue can clear lipiodol, there is a significant contrast between tumor and liver tissue, which improves the sensitivity of diagnosis and facilitates the discovery of microscopic foci in the liver. CT and ultrasound are complementary to the localization and diagnosis of cancer. The scope of the swelling has great value, and overcomes the shortcomings that the ultrasonography is not easy to detect the facial surface. However, the current examination method still uses CT plain scan plus enhancement as a conventional method, and special contrast method is used for suspicious lesions or microscopic liver cancer. To study the transverse anatomy of the liver, to understand the relationship between the tumor and the inferior vena cava and the superior mesenteric tumor thrombus and the para-aortic lymph node metastasis, etc. CT diagnosis of liver cancer is insufficient for diffuse liver cancer, equal density lesions Missed diagnosis.
3. Magnetic resonance imaging (MRI) The diagnosis of hepatocellular carcinoma by magnetic resonance imaging is similar to that of CT. Nuclear magnetic resonance is helpful in identifying hepatocellular carcinoma nodules and cirrhotic nodules. The T1 time of liver cancer nodules is shorter, which is better than Other diagnostic methods other than hepatic angiography, MRI can provide further information for the identification of metastatic liver cancer, hemangioma and hamartoma. T1 and T2 relaxation time is prolonged in liver cancer, and T1 weighted tumors in more than half of cases are compared with surrounding liver. Tissue low signal intensity or equal signal intensity, while high signal intensity is shown on the T2-weighted map, characteristic features of primary liver cancer MRI:
T1T1T2T1
T1T2
MRIT1T2
T2MRICT
12.X 88%93%2cm
;
;
;
;
;
;
2cmBCT;
(DSA)
12. 3cm92.3%99mTc-PMT(99mTc)PMT(25h)99mTc-PMTAFP99mTc-PMT>90%
13.
AFP;AFPAFPCT
Diagnosis
Diagnostic criteria
1.
(1)
(alpha-fetoproteinAFP)60%70PAFPAFPAFPAFPAFP400ng/ml1200ng/ml2AFP612AFP
AFPAFP
(ALP)1320%
-(-GT)4070%200
(2)80%
(3)(OT)(NK)T
2. Imaging
(1)XX
(2)(ultrasonographyUS)
(3)(computer tomographyCT)CTCTCT90%
CT(CTA)0.5cm
(4)(MRI)CTCT
(5)CTB
(6)BCTMRI(SPECT)(PET)2cm
3.BCT
4.
Differential diagnosis
1.
AFP
2.
AFPAFP500µg/ml
3.
4.
CTMRI
