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Diagnosis and treatment of early-stage liver cancer in China

Liver cancer ( mainly hepatocellular carcinoma ) is the fourth most common malignant tumour in terms of annual incidence , and the second in terms of mortality in China . Extensive screening is expected to enable more patients with liver cancer to be diagnosed earlier and improve the overall benefits of the liver cancer population .
Zhang Hui Department of Hepatopancreatobiliary Surgical Oncology , Fujian Cancer Hospital and Fujian Medical University Cancer Hospital , China
Liu Jingfeng Department of Hepatopancreatobiliary Surgical Oncology , Fujian Cancer Hospital and Fujian Medical University Cancer Hospital , China
Primary liver cancer is a common malignant tumour that seriously threatens life and the health of people in China . Results from large-scale analysis of disease burden and risk factors in the last 40 years showed that liver cancer was one of the five main causes for premature death . 1 As estimated by the World Health Organization , new cases and deaths from liver cancer in China in 2018 accounted for nearly half of the global cases , 2 and 5-year survival rate ( 12.1 %) was the lowest among common cancers . 3
Hepatocellular carcinoma ( HCC ) is the main primary liver cancer , accounting for about 85 %– 90 % of cases . In China , the main risk factor for development of HCC is viral hepatitis , whereas risk factors in Europe and the US are alcoholic liver disease and non-alcoholic fatty liver disease . Many patients are already at an advanced stage at the time of diagnosis and therefore have limited treatment regimens and significantly shortened life expectancy . 4 Since 2007 , early screening of liver cancer has been adopted in many regions of China , which not only increased 5-year survival rate , but also increased the percentage of patients who could receive local treatment regimens as more were diagnosed with early-stage disease . Therefore , clinical management of early-stage liver cancer is becoming increasingly important . 5
Screening the high-risk liver cancer population Relevant guidelines and clinical practice guidelines for screening of populations at high-risk of liver cancer have been issued in China . As pointed out in the Guidelines for Diagnosis and Treatment of Primary Liver Cancer ( 2019 edn ), high-risk factors for liver cancer include : hepatitis B or hepatitis C virus infection ; long-term excessive alcohol use ; non-alcoholic steatohepatitis ; intake of foods contaminated by aflatoxin ; liver cirrhosis ; and family history of liver cancer . 6 Screening with ultrasound and alpha fetoprotein ( AFP ) testing is recommended for these high-risk populations . Moreover , AFP combined with ultrasound has a higher screening sensitivity than ultrasound alone . 7 , 8 The Guideline for Stratified Screening and Surveillance of Primary Liver Cancer ( 2020 edn ) stratifies populations at risk of liver cancer and provides surveillance intervals and tools . 9
Clinical management Surgical treatment of resectable liver cancer Unlike the Barcelona Clinic Liver Cancer method adopted in Europe and the US , the CNLC 4-stage method is used for clinical staging of liver cancer in China . Surgical indications are applicable to patients at stages CNLC Ia , Ib , and IIa and having a good hepatic function reserve . Stage IIb disease particularly benefits from surgery . However , if the tumour is only observed in the same hepatic segment or the same side of the liver , or lesions outside the range can be removed by radiofrequency ablation ( RFA ), surgical treatment is still the optimal choice .
Both diligence and safety of the hepatectomy is crucial . Single and multiple lesions should be meticulously resected without leaving residual tumour on the incisal margin , imaging features of vessel invasion above the hepatic segments , or extrahepatic metastatic tumour . Enough functional liver tissue after operation to achieve compensation , and reduce operative mortality and the risk of complications should be ensured .
Both laparoscopy and routine laparotomy are used for liver resection . Laparoscopic hepatectomy is preferred for liver resection of fewer than three segments or for lesions close to the liver margin . Laparoscopic radiofrequency ablation is conducive to preserving more functional liver tissue , so patients with hepatic injury are eligible for this method of treatment .
Residual or recurring tumours are examined using B-mode ultrasound , CT and / or MRI two months after operation . Furthermore , whether radical excision has been achieved can be evaluated through postoperative AFP testing and recovery of abnormal biochemical indicators such as prothrombin complex II .
Adjuvant / neoadjuvant therapy There is a 50 %– 70 % recurrence rate in liver cancer patients 5 years after hepatectomy but there is no globally recognised postoperative
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