Zusammenfassung
Das hepatozelluläre Karzinom ist das häufigste primäre Lebermalignom. In den meisten Fällen entwickelt sich der Tumor auf dem Boden einer Leberzirrhose. Als Tumormarker gilt das α-Fetoprotein. Bei bekannter Leberzirrhose sollen regelmäßige Screening-Untersuchungen unter Einschluss der Sonographie und der α-Fetoprotein-Bestimmung erfolgen. Chirurgische Therapie, entweder in Form von partieller Leberresektion oder Lebertransplantation, stellt die einzige Therapieoption mit der Möglichkeit eines Langzeitüberlebens dar. Bei Patienten mit einer Leberzirrhose beeinträchtigen die postoperative Leberinsuffizienz und hohe lokale Tumorrezidivraten die Ergebnisse der Resektion. Als geeignete Resektionskandidaten gelten Patienten ohne Leberzirrhose oder Zirrhosepatienten im Child-Pugh-Stadium A mit Tumoren kleiner als 5 cm. Für Patienten in höheren Zirrhosestadien mit Tumoren kleiner als 5 bis 7 cm bedeutet die Lebertransplantation die bessere therapeutische Option. Die Ergebnisse der Lebertransplantation werden durch die Wartezeit auf ein geeignetes Spenderorgan negativ beeinflusst. Die Lebendleberspende bietet eine neue Behandlungsmöglichkeit mit der Option der Verbesserung der Überlebensraten nach der Transplantation und der Erweiterung der Indikation zur Transplantation.
Abstract
Hepatocellular carcinoma (HCC) accounts for most primary malignancies of the liver. The most important risk factor is liver cirrhosis. HCC can be traced by the tumor marker α-fetoprotein. Patients with a known liver cirrhosis should regularly be screened, including sonography and α-fetoprotein evaluation. Surgical therapy - either partial liver resection or liver transplantation - is the only treatment that can potentially achieve long-term survival. The presence of liver cirrhosis is likely to induce postoperative liver insufficiency and is associated with higher local tumor recurrence rate. Patients without liver cirrhosis or Child-Pugh A patients with tumors smaller than 5 cm may be considered as the ideal target group for resection. For more advanced stages of cirrhosis and tumors of less than 5 cm up to 7 cm in size, liver transplantation offers a better prognosis. Long waiting time for a suitable organ negatively influences liver transplantation outcome. Living donor liver transplantation is a novel therapeutic option that improves posttransplant survival and extends the indication for transplantation in hepatocellular carcinoma.
Schlüsselwörter
Hepatozelluläres Karzinom - Leberzirrhose - Leberresektion - Lebertransplantation
Key words
Hepatocellular carcinoma - liver cirrhosis - liver resection - liver transplantation
Literatur
-
1
Arii S, Yamaoka Y, Futagawa S, Inoue K, Kobayashi K, Kojiro M. et al .
Results of surgical and nonsurgical treatment for small-sized hepatocellular carcinomas: a retrospective and nationwide survey in Japan.
Hepatology.
2002;
32
1224-1229
-
2
Bosch F X, Ribes J, Borras J.
Epidemiology of primary liver cancer.
Semin Liver Dis.
1999;
19
271-285
-
3
Bruix J, Sherman M, Llovet M J, Beaugrand M, Lencioni R, Burroughs A K, Christensen E, Pagliaro L, Colombo M, Rodes J. for the EASL Panel of Experts on HCC .
Clinical management of hepatocellular carcinoma. Conclusion of the Barcelona-2000 EASL conference.
J Hepatol.
2001;
35
421-430
-
4
Bruix J, Llovet J M.
Prognostic prediction and treatment strategy in hepatocellular carcinoma.
Hepatology.
2002;
35
519-524
-
5
Busuttil R W, Farmer D G.
The surgical treatment of primary hepatobiliary malignancy.
Liver Transpl Surg.
1996;
2
114-130
-
6
Chevret S, Trinchet J C, Mathieu D, Rached A A, Beaugrand M, Chastang C.
A new prognostic classification for predicting survival in patients with hepatocellular carcinoma.
J Hepatol.
1999;
31
133-141
-
7
CLIPP .
Prospective validation of the CLIP score: a new prognostic system for patients with cirrhosis and hepatocellular carcinoma.
Hepatology.
2000;
31
840-845
-
8
El-Serag H B.
Hepatocellular carcinoma and hepatitis C in the United States.
Hepatology.
2002;
36
74-83
-
9
Fan S T, Ng I OL, Poon R TP. et al .
Hepatectomy for hepatocellular carcinoma; the surgeon 's role in long-term survival.
Arch Surg.
1999;
134
1124-1130
-
10
Farges O, Malassagne B, Flejou J F, Balzan S, Sauvanet A, Belghiti J.
Risk of major liver resection in patients with underlying chronic liver disease. A reappraisal.
Ann Surg.
1999;
229
210-215
-
11
Fattovich G.
Progression of hepatitis B and C to hepatocellular carcinoma in western countries.
Hepato-Gastroenterology.
1998;
45
1206-1213
-
12
Figueras J, Ibanez L, Ramos E, Jaurrieta E, Ortiz- de-Urbina J, Pardo F. et al .
Selection criteria for liver transplantation in early-stage hepatocellular carcinoma with cirrhosis: results of a multicenter study.
Liver Transpl.
2001;
7
877-883
-
13
Fong Y, Sun R L, Jarnagin W, Blumgart L H.
An analysis of 412 cases of hepatocellular carcinoma at a Western center.
Ann Surg.
1999;
229
790-799
-
14
Freeman R B.
Diagnosing hepatocellular carcinoma: a virtual reality.
Liver Transpl.
2002;
8
762-764
-
15
Fuster J, Garcia-Valdecasas J C, Grande L, Tabet J, Bruix J, Anglada T. et al .
Hepatocellular carcinoma and cirrhosis. Results of surgical treatment in a European series.
Ann Surg.
1996;
223
297-302
-
16
Gebo K A, Chander G, Jenckes M W, Ghanem K G, Herlog F, Torbenson M S. et al .
Screening tests for hepatocellular carcinoma in patients with chronic hepatitis C: a systematic review.
Hepatology.
2002;
36
84-92
-
17
Grazi G L, Ercolani G, Pierangeli F, Del Gaudio M, Cescon M, Cavallari A, Mazziotti A.
Improved results of liver resection for hepatocellular carcinoma on cirrhosis give the procedure added value.
Ann Surg.
2001;
234
71-78
-
18
Hemming A W, Cattral M S, Reed A I, Van der Wert W J, Greig P D, Howard R J.
Liver transplantation for hepatocellular carcinoma.
Ann Surg.
2001;
233
652-659
-
19
Iannitti D A, Dupuy D E, Mayo-Smith W W, Murphy B.
Hepatic radiofrequency ablation.
Arch Surg.
2002;
137
422-427
-
20
Iwatsuki S, Dvorchik I, Marsh J W, Madariaga J R, Carr B, Fung J J.
Liver transplantation for hepatocellular carcinoma: a proposal of a prognostic scoring system.
J Am Coll Surg.
2000;
191
389-394
-
21
Izzo F, Cremona F, Ruffolo F, Palaia R, Parisi V, Curley S A.
Outcome of 67 patients with hepatocellular cancer detected during screening of 1 125 patients with chronic hepatitis.
Ann Surg.
1998;
227
513-518
-
22
Jamagin W R, Gonen M, Fong Y, DeMatteo R P, Ben-Porat L, Little S. et al .
Improvement in perioperative outcome after hepatic resection. Analysis of 1 803 consecutive cases over the past decade.
Ann Surg.
2002;
236
397-407
-
23
Kanematsu T, Furui J, Yanaga K, Okadaira S, Shimada M, Shirabe K.
A 16-year experience in performing hepatic resection in 303 patients with hepatocellular carcinoma: 1985-2000.
Surgery.
2002;
131
153-158
-
24
Kim T, Murakami T, Takahashi S, Tsuda K, Tomoda K, Narumi Y. et al .
Optimal phases of dynamic CT for detecting hepatocellular carcinoma: evaluation of unenhanced and triple-phase images.
Abdom Imaging.
1999;
24
473-480
-
25
Libbrecht L, Bielen D, Verslype C, Vanbeckevoort D, Pirenne J, Nevens F, Desmet V. et al .
Focal lesions in cirrhotic explant livers: pathological evaluation and accuracy of pre-transplant imaging examination.
Liver Transpl.
2002;
8
749-761
-
26
Llovet J M, Bru C, Bruix J.
Prognosis of hepatocellular carcinoma: the BCLC staging classification.
Semin Liver Dis.
1999;
19
329-338
-
27
Llovet J M, Fuster J, Bruix.
Intention-to-treat analysis of surgical treatment for early hepatocellular carcinoma: resection versus transplantation.
Hepatology.
1999;
30
1434-1440
-
28
Llovet J M, Bruix J, Gores G J.
Surgical resection versus transplantation for early hepatocellular carcinoma: clues for the best strategy.
Hepatology.
2000;
31
1019-1021
-
29
Molmenti E P, Klintmalm G B.
Liver transplantation in association with hepatocellular carcinoma: an update of the International Tumor Registry.
Liver Transpl.
2002;
8
736-748
-
30
Olthoff K M, Millis J M, Rosove M H, Goldstein L I, Ramming K P, Busuttil R W.
Is liver transplantation justified for the treatment of hepatic malignancies?.
Arch Surg.
1990;
125
1261-1266
-
31
Penn I.
Hepatic transplantation for primary and metastatic cancers of the liver.
Surgery.
1991;
110
726-734
-
32
Poon R TP, Fan S T, O’ Suilleabhain C B, Wong J.
Aggressive management of patients with extrahepatic and intrahepatic recurrence of hepatocellular carcinoma by combined resection and locoregional therapy.
J Am Coll Surg.
2002;
195
311-318
-
33
Poon R TP, Fan S T, Wong J.
Selection criteria for hepatic resection in patients with large hepatocellular carcinoma larger than 10 cm in diameter.
J Am Coll Surg.
2002;
194
592-602
-
34
Poon R TP, Fan S T, Tsang F HF, Wong J.
Locoregional therapies for hepatocellular carcinoma: a critical review from the surgeon's perspective.
Ann Surg.
2002;
235
466-486
-
35
Ringe B, Wittekind C, Bechstein W O, Bunzendahl H, Pichlmayr R.
The role of liver transplantation in hepatobiliary malignancy. A retrospective analysis of 95 patients with particular regard to tumor stage and recurrence.
Ann Surg.
1989;
209
88-98
-
36
Roayaie S, Frischer J S, Emre S H, Fishbein T M, Sheiner P A, Sung M. et al .
Long-term results with multimodal adjuvant therapy and liver transplantation for the treatment of hepatocellular carcinomas larger than 5 cm.
Ann Surg.
2002;
235
533-539
-
37
Ruiz J, Mazzolini G, Sangro B, Qian C, Prieto J.
Gene therapy of hepatocellular carcinoma.
Dig Dis.
2001;
19
324-332
-
38
Suehiro T, Terashi T, Shiotani S, Soejima Y, Sugimachi K.
Liver transplantation for hepatocellular carcinoma.
Surgery.
2002;
131
190-194
-
39
Sugimachi K, Maehara S, Tanaka S, Shimada M, Sugimachi K.
Repeat hepatectomy is the most useful treatment for recurrent hepatocellular carcinoma.
J Hepatobiliary Pancreat Surg.
2001;
8
410-416
-
40
Tanaka H, Hirohashi K, Kubo S, Shuto T, Higaki I, Kinoshita H.
Preoperative portal vein embolization improves prognosis after right hepatectomy for hepatocellular carcinoma in patients with impaired hepatic function.
Br J Surg.
2000;
87
879-882
-
41
Wayne J D, Lauwers G Y, Ikai I, Doherty D A, Belghiti J, Yamaoka Y. et al .
Preoperative predictors of survival after resection of small hepatocellular carcinomas.
Ann Surg.
2002;
235
722-731
-
42
Yamamoto J, Okada S, Shimada K, Okusaka T, Yamasaki S, Ueno H. et al .
Treatment strategy for small hepatocellular carcinoma: comparison of long-term results after percutaneous ethanol injection therapy and surgical resection.
Hepatology.
2001;
34
707-713
-
43
Yao F Y, Ferrell L, Bass N M, Bacchetti P, Ascher N L, Roberts J P.
Liver transplantation for hepatocellular carcinoma: comparison of the proposed UCSF criteria with the Milan criteria and the Pittsburgh modified TNM criteria.
Liver Transpl.
2002;
8
765-774
-
44
Yang H I, Lu S N, Liaw Y F, You S L, Sun C A, Wang L Y. et al .
Hepatitis B e antigen and the risk of hepatocellular carcinoma.
N Engl J Med.
2002;
347
168-174
-
45
Yokoyama I, Todo S, Iwatsuki S, Starzl T E.
Liver transplantation in the treatment of primary liver cancer.
Hepatogastroenterology.
1990;
37
188-193
Prof. Dr. A. Frilling
Klinik für Allgemein- und Transplantationschirurgie
Universitätsklinikum Essen
Hufelandstr. 55
45122 Essen
Telefon: 02 01/7 23 11 11
Fax: 02 01/7 23 59 46
eMail: frilling@uni-essen.de
