Diagnostik des hepatozellulären Karzinoms

Zusammenfassung

Risikofaktoren und Symptome des hepatozellulären Karzinoms (HCC): Eine Leberzirrhose aufgrund von Infektionen mit dem Hepatitis-B- oder -C-Virus oder Alkoholabusus ist Hauptrisikofaktor für die Entstehung eines hepatozellulären Karzinoms. Das Fehlen von spezifischen Symptomen erschwert die frühzeitige Diagnosestellung. Screening von Patienten mit Leberzirrhose: Der gebräuchlichste Tumormarker in der Diagnostik des HCCs ist das Alpha-Fetoprotein (AFP). Der Nutzen anderer serologischer Marker wie zum Beispiel des Des-gamma-carboxy-prothrombins (DGCP) oder Fraktionen des AFPs (AFP-L3) werden in diesem Zusammenhang diskutiert. Ultraschalluntersuchungen der Leber sollten bei Patienten mit Leberzirrhose alle 6 (- 12) Monate durchgeführt werden. Überwachung der solitären Raumforderung in der Zirrhoseleber: Die Sonografie stellt die häufigste bildgebende Methode in der Detektion des hepatozellulären Karzinoms dar, wobei in der Literatur sehr unterschiedliche Sensitivitäten für die Methode angegeben werden. Sonografisch kann ein HCC echoarm, echogleich zum übrigen Lebergewebe oder echoreich imponieren, es kann rundlich oder oval sein und sich glatt oder unregelmäßig abgrenzen. Farbdoppler- und powerdopplersonografisch zeigen sich irregulär verlaufende, intratumorale Gefäßsignale. In der Differenzialdiagnose kleinerer maligner Raumforderungen in der zirrhotischen Leber ist die Kontrastmittelsonografie hilfreich. Die Computertomografie (CT) und die Magnetresonanztomografie (MRT) mit und ohne Kontrastmittel spielen sowohl in der Diagnostik als auch im Stagingprozess des HCCs eine wichtige Rolle. Zur definitiven Diagnosesicherung ist gegebenenfalls die Histologie nötig. Vorgehen bei bekanntem HCC: Verschiedene Tumormarker werden in der Beurteilung der Tumorprogression und zur Einschätzung von Prognose und Therapieerfolg eingesetzt. Unter verschiedenen Stagingsystemen des hepatozellulären Karzinoms stellt das „Barcelona-Clinic-Liver-Cancer (BCLC) staging system” derzeit das einzige Stagingsystem dar, welches neben dem Tumorstadium auch Parameter der Leberfunktion, den Allgemeinzustand des Patienten und weitere, tumorassoziierte Symptome berücksichtigt. Was die Therapieoptionen des HCCs angeht, spielen neben der Tumorresektion auch nicht chirurgischen Behandlungsmethoden wie die perkutane Ethanolinjektion (PEI), die Radiofrequenzablation (RFTA) oder die transarterielle Chemoembolisation (TACE) eine Rolle. Diese lokal ablativen Verfahren kommen bei ausgewählten Patienten mit HCC auch zur Überbrückung bis zur orthotopen Lebertransplantation zum Einsatz. Die Kontrastmittelsonografie ermöglicht die Kontrolle der lokalen Ablationserfolge.

Abstract

Risk factors and symptoms of hepatocellular carcinoma (HCC): The main risk factors of HCC include infection with hepatitis B or C virus, as well as alcohol consumption. There are no specific symptoms of HCC, making early diagnosis and detection of the disease difficult. When HCC presents with specific clinical symptoms, the tumour is typically very far advanced. Surveillance in liver cirrhosis: The most common serological marker used in HCC diagnosis is alpha-fetoprotein (AFP), but other tumour markers such as the des-gamma-carboxyprothrombin (DGCP) or fractions of AFP (AFP-L3) exist and there use is discussed in this context. Surveillance should be done by sonography at 6 (to 12) months intervals. The single nodule in the cirrhotic liver: Ultrasound is the most commonly used imaging modality for detecting HCC tumour nodules with a large range of reported sensitivities. HCC may appear as a hypoechoic, isoechoic, or hyperechoic round or oval lesion with intratumoural flow signals on Doppler or power Doppler sonography. The differentiation of smaller malignant lesions in cirrhotic livers can be improved by contrast-enhanced ultrasound (CEUS). Spiral computed tomography (CT) and magnetic resonance imaging (MRI) with and without contrast enhancement play an important role in the diagnosis and staging of HCC. If the vascular pattern on imaging is not typical, biopsy becomes necessary. The patient with known HCC: Different tumour markers are used in the evaluation of tumour progression, prediction of patient outcome and treatment efficacy. Among the various staging systems used in the context of HCC, the Barcelona-Clinic-Liver-Cancer (BCLC) staging system is currently the only staging system that takes into account tumour stage, liver function, physical status and cancer-related symptoms. Beside surgical resection, non-surgical treatments such as percutaneous ethanol injection (PEI), radiofrequency thermoablation (RFTA) and trans-arterial chemoembolisation (TACE) are used. Successful tumour “bridging” with ablative therapy methods can be achieved in carefully selected patients on the waiting list for orthotopic liver transplantation. Contrast-enhanced sonography is able to control the ablation treatment of HCC.

Schlüsselwörter

Leber - HCC - Diagnostik

Key words

liver - HCC - diagnostics

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