How to prevent recurrence of liver cancer ?

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Liver cancer prevention

Preventing recurrence of liver cancer, preventing recurrence of liver cancer after surgery, how to prevent recurrence of liver cancer, how to prevent recurrence of liver cancer

Liver cancer is the second leading cause of cancer death in the world, of which hepatocellular carcinoma (HCC) is the most common type of liver cancer. Globally, nearly half of new cases of liver cancer occur in China. The treatment options for patients with advanced hepatocellular carcinoma are very limited. The currently approved treatment options have a tumor progression-free survival of about 3-7 months and a total survival of about 9-13 months

The five-year survival rate of liver cancer

The five-year survival rate of patients with liver cancer is low, according to data from the US ASCO official website:

44% of patients were diagnosed with early-stage liver cancer and their 5-year survival rate was 31%.

If liver cancer has spread to surrounding tissues or organs and/or regional lymph nodes, the 5-year survival rate is 11%.

If cancer has spread far away from the body, the 5-year survival rate is 2%.

However, even if cancer is found to be at an advanced stage, various treatments can be used to help patients with liver cancer prolong their survival. Surgery is the best treatment option for patients with liver cancer. Most patients think of surgical resection first, but they still face the risk of recurrence after surgical resection.

How to effectively prevent the recurrence of liver cancer? 

Periodic review

Compared with malignant tumors such as breast cancer and lung cancer, the recurrence rate of liver cancer is relatively high: Generally, the recurrence rate after three years is about 40% -50%, and the recurrence rate after five years is 60% -70% .

Therefore, it is necessary to review regularly and follow the doctor’s order, even if early signs of metastasis are found, there is still a chance to be resected surgically. If the whole body metastases are discovered due to neglect of review, treatment will be extremely difficult.

Items that need to be checked for regular liver cancer review include:

Liver function test

Liver function tests are generally the most capable of detecting the current state of the liver for diseases and inflammations, but they often fail to detect the presence of cirrhosis and liver cancer, and they cannot detect whether they are infected with various hepatitis viruses.

Alpha fetoprotein

If the preoperative alpha-fetoprotein positive decreases to normal after surgical removal of liver cancer, and then increases again, there is no explanation for chronic active liver disease, which indicates that liver cancer has recurred.

For patients with negative alpha-fetoprotein before liver cancer resection, alpha-fetoprotein can be positive during recurrence, and alpha-fetoprotein should still be followed up after surgery.

Abdominal ultrasound

B-ultrasound has the advantages of sensitivity, convenience, and low cost. It is an important method for monitoring the recurrence of liver cancer. Abdominal ultrasound is an essential test

Chest radiography

Some recurrent lesions first occur in the lungs, so chest X-rays are needed to monitor the chest for recurrence.

CT, PET-CT

When the doctor is still not sure whether to transfer after the B-ultrasound, CT scan should be done in time. If there is any other metastasis in another part, then a whole body PET-CT check is performed. Conditioned liver cancer patients can have a PET-CT examination once a year to detect tumors larger than 2mm in the whole body at one time, reducing the complexity and uncertainty of many tests.

Change lifestyle

Quit alcohol, quit alcohol, quit alcohol, important things are said three times, you must quit alcohol. Also, don’t smoke, don’t overwork, and stay happy.

Appropriate exercise, 2-3 months after surgery, you can do gentle exercises, such as walking, and gradually increase from 15 minutes to 40 minutes; you can also exercise qigong, Tai Chi, radio exercises and other gentle exercises.

Special attention should be paid to the diet, do not eat moldy food, barbecue, bacon, tofu and other foods containing nitrite, and do not eat traditional Chinese medicine and health products.

The postoperative diet is mainly light, and the intake of high-quality protein such as egg white and lean meat is appropriately increased. The postoperative diet generally transitions from water, porridge, milk, steamed eggs, fish, lean meat to ordinary diet.

Try to eat easily digestible foods, avoid greasy, spicy, irritating, hard, sticky and other foods, eat a balanced diet, eat fewer meals, and should not be full.

How to prevent the recurrence of liver cancer after surgery?

At present, the main treatment options for liver cancer include liver transplantation (liver replacement), liver cancer resection, transcatheter arterial chemoembolization, radiofrequency ablation / microwave ablation, high-intensity focused ultrasound (HIFU), absolute alcohol injection, molecular targets To drugs, etc., while radiotherapy, chemotherapy, and immunotherapy are adjuvant treatments, generally not as the main treatment plan.

Surgery clean

The most ideal method for liver cancer treatment is to remove tumor lesions to achieve the goal of radical cure. If the surgical criteria are met, all tumors can be removed surgically.

If there are multiple lesions, the invasion area is relatively large, or distant metastases, tumor resection can be selected according to the situation. In the case that the benefit of surgery is not guaranteed, other treatment methods can be selected.

Minimally invasive treatment

Minimally invasive treatment is a unique method for liver cancer treatment, including the following three:

1. Transcatheter arterial chemoembolization

Insert a tube from the femoral artery of the lower limb or the radial artery of the upper limb to the liver, and block the arteries that feed the tumor, and the tumor will undergo ischemic necrosis. At the same time, chemotherapeutic drugs are perfused into the tumor with lipiodol. In the case of affecting the surrounding normal liver tissue, tumor cells can be further killed.

2.Chemical ablation

Usually under the guidance of B ultrasound or CT, injection of absolute alcohol into the tumor site makes the tumor cells quickly dehydrate and the proteins denature and coagulate, thereby killing the tumor cells, but this method is currently less used.

3. Physical ablation

Including radiofrequency ablation and microwave ablation, also under the guidance of B ultrasound or CT, the tumor cells are killed by the thermogenic effect of the puncture needle.

Radiotherapy in liver cancer

Radiotherapy is usually used as a complementary treatment. For liver cancer in special locations (such as intravascular, biliary tract, or adjacent large veins), minimally invasive treatment cannot be achieved, or minimally invasive treatment cannot be performed cleanly. Radiotherapy can be selected.

Proton therapy in liver cancer treatment

Radiotherapy is an adjuvant treatment for many patients with liver cancer after surgery. However, in traditional radiotherapy, X-rays or photon beams are inevitably transmitted to the tumor site and the surrounding healthy tissues. This can damage nearby healthy tissue and can cause serious side effects. Proton therapy can perfectly avoid these side effects.

In contrast, proton therapy uses proton beam irradiation and can stop at the tumor site without leaving a radiation dose behind the tumor, so it is u
nlikely to damage nearby healthy tissue. Some experts believe that proton therapy is safer than traditional radiation therapy. Cancer patients have low immunity, high-intensity radiation exposure can easily cause damage to normal organs, cause serious adverse reactions, and bring a serious burden to the already weak body. Especially for liver cancer, tumor lesions are next to many important organs, such as lung, heart, esophagus, etc. There are also common brain metastases. Choosing proton therapy can effectively avoid damage to surrounding healthy tissues and achieve tumor-killing like traditional radiotherapy effect.

Medical treatment of liver cancer

1. Chemotherapy

Chemotherapy includes systemic chemotherapy and local chemotherapy. Local chemotherapy is the transcatheter arterial chemoembolization mentioned above. The effectiveness of systemic chemotherapy is less than 10%, and the side effects are serious. Most patients will not choose.

2.Targeted therapy

Targeted drugs approved for liver cancer at home and abroad

date FDA approves liver cancer targeted drug Indication Domestic approvals
November 2007 Sorafenib (Sorafenib, Nexavar) For the treatment of unresectable hepatocellular carcinoma or liver cancer Listing and inclusion in health insurance
August 2018 Lenvatinib (Levatinib, Lenvima) For first-line treatment of unresectable hepatocellular carcinoma Go public
April 2017 Regorafenib (Sigvarga) Second-line treatment for sorafenib-resistant liver cancer Listing and inclusion in health insurance
September 2017 Nivolumab (navumab, Opdivo) Second-line treatment for sorafenib-resistant liver cancer Go public
November 2018 Pembrolizumab (Keytruda) Second-line treatment for sorafenib-resistant liver cancer Go public
January 2019 Cabozantinib (Cabometyx) Second-line treatment for sorafenib-resistant liver cancer Go public
May 2019 Ramucirumab (Rimolimumab, Cyramza) Monotherapy for hepatocellular carcinoma patients with alpha-fetoprotein (AFP) ≥400ng / ml and previously treated with sorafenib Unlisted

Choice of first-line treatment for liver cancer

(1) Sorafenib

A number of clinical studies have shown that Sorafenib has certain survival benefits for patients with advanced liver cancer in different countries and backgrounds with different liver diseases (level of evidence 1).

The usual recommended usage is 400 mg orally, twice daily. Can be used for Child-Pugh Class A or B patients with liver function. Compared with Child-Pugh B liver function, Child-Pugh A patients’ survival benefit is more obvious.

Need to pay attention to the impact on HBV and liver function, and promote the management of basic liver disease throughout the process. The most common adverse reactions are diarrhea, weight loss, hand and foot syndrome, rash, myocardial ischemia, and hypertension, which usually occur within 2 to 6 weeks after the start of treatment.

(2) Lemvatinib

Lenvatinib is suitable for unresectable patients with stage IIb, IIIa, IIIb, liver function Child-Pugh A liver cancer, and its first-line treatment is not inferior to sorafenib. HBV-related liver cancer has better Survival benefits [185] (level of evidence 1).

Lenvatinib has been approved for use in Child-Pugh A liver cancer patients with advanced liver cancer. Usage: 12mg, oral, once daily for body weight ≥60kg; 8mg, oral, once daily for body weight <60kg. Common adverse reactions are hypertension, diarrhea, decreased appetite, fatigue, hand-foot syndrome, proteinuria, nausea, and hypothyroidism.

(3) Systemic chemotherapy

The FOLFOX4 (fluorouracil, calcium folinate, oxaliplatin) protocol is approved in China for the treatment of locally advanced and metastatic liver cancer that is not suitable for surgical resection or local treatment (level of evidence 1).

Multiple phase II studies have reported that systemic chemotherapy with oxaliplatin combined with sorafenib can improve objective response rates, extend progression-free survival and overall survival, and provide good safety (level of evidence 3).

For patients with good liver function and physical status, this combination therapy can be considered, but clinical randomized controlled studies are still needed to provide high-level evidence-based medical evidence. In addition, arsenic trioxide has a certain palliative treatment effect on advanced liver cancer (level of evidence 3). In clinical application, care should be taken to monitor and prevent liver and kidney toxicity.

Second-line treatment of liver cancer

(1) Regorafenib

Regorafenib is approved for use in patients with stage IIb, IIIa, and IIIb CNLC liver cancer who have previously been treated with sorafenib (evidence level 1). The usage is 160mg once daily for 3 weeks and discontinued for 1 week.

In China, the initial dose can be 80mg or 120mg once, once a day, and gradually increased according to the patient’s tolerance. Common adverse events are hypertension, hand-foot skin reactions, fatigue, and diarrhea.

 

(2) Navumab and Paimumab

The US FDA has approved the use of Navulinu monoclonal antibodies (Nivolumab) and Pabrolizumab monoclonal antibodies (Pembrolizumab) in patients with liver cancer who have progressed or cannot tolerate sorafenib after previous sorafenib treatment (level of evidence 2).

At present, immunological checkpoint inhibitors independently developed by Chinese companies, such as Carellidizum monoclonal antibodies, Treplepril monoclonal antibodies, and Xindili monoclonal antibodies, are undergoing clinical research. The combination of immunotherapy and targeted drugs, chemotherapeutic drugs, and topical treatments is also constantly being explored.

Other immunomodulators (such as interferon α, thymosin α1, etc.), cellular immunotherapy (such as chimeric antigen receptor T cell therapy, CAR-T, and cytokine-induced killer cell therapy, CIK) all have certain antitumor effects. However, it is yet to be verified by large-scale clinical studies.

(3) Second-line treatment options available in the United States

In addition, the U.S. FDA approves cabozantinib for patients with liver cancer that has progressed after first-line system therapy (evidence level 1), and approves the use of Lemorex monoclonal antibody for second-line treatment of patients with liver AFP levels ≥400ng / mL (evidence level 1) ). However, these two drugs have not been marketed in China. The clinical research of domestic small-molecule anti-angiogenesis targeting drug apatinib for second-line treatment of liver cancer patients is ongoing.

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