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中华腔镜外科杂志(电子版) ›› 2025, Vol. 18 ›› Issue (05) : 264 -270. doi: 10.3877/cma.j.issn.1674-6899.2025.05.002

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多灶性肝细胞癌的手术策略——外科医师视角
张珅瑜, 王继洲()   
  1. 230001 合肥,中国科学技术大学附属第一医院肝胆外科
  • 收稿日期:2025-10-10 出版日期:2025-10-30
  • 通信作者: 王继洲
  • 基金资助:
    国家自然科学基金(82170618); 安徽省高校杰出青年科研项目(2024AH020016); 合肥综合性国家科学中心先导医学与前沿技术研究所项目(2023IHM01020)

Surgical strategies for multifocal hepatocellular carcinoma - from the perspective of surgeons

Shenyu Zhang, Jizhou Wang()   

  1. Department of Hepatobiliary Surgery, First Affiliated Hospital of University of Science and Technology of China, Hefei 230001, China
  • Received:2025-10-10 Published:2025-10-30
  • Corresponding author: Jizhou Wang
引用本文:

张珅瑜, 王继洲. 多灶性肝细胞癌的手术策略——外科医师视角[J/OL]. 中华腔镜外科杂志(电子版), 2025, 18(05): 264-270.

Shenyu Zhang, Jizhou Wang. Surgical strategies for multifocal hepatocellular carcinoma - from the perspective of surgeons[J/OL]. Chinese Journal of Laparoscopic Surgery(Electronic Edition), 2025, 18(05): 264-270.

多灶性肝细胞癌因高度的肿瘤异质性导致治疗策略复杂化。全球指南对手术指征的界定存在地域差异:西方指南优先推荐符合米兰标准的多灶性肝癌患者接受肝移植,而亚太地区更倾向于肝切除术,即使在中晚期患者(包括肿瘤负荷较高、肝功能受损和体能状态较差的患者)中也采取更为积极的手术策略。近年研究显示,肝切除术可以显著延长部分中晚期多灶性肝癌患者的生存期。随着微创技术、转化治疗及围术期综合治疗的进步,多灶性肝癌手术适应证进一步扩大,且生存获益有了质的提升。未来,手术、局部及系统治疗等技术的多学科策略整合对于制定个性化、精准化和标准化的治疗方案至关重要。同时,循证医学和技术创新的进步对于优化多灶性肝癌患者的长期预后同样不可或缺。

Multifocal hepatocellular carcinoma (MHCC) complicates the treatment strategy due to its high tumor heterogeneity. Global guidelines exhibit regional variations in defining surgical indications: Western guidelines prioritize liver transplantation for patients with MHCC meeting Milan criteria, while Asia-Pacific regions demonstrate greater preference for liver resection (LR), adopting more positive strategy even in intermediate-advanced stage patients (including those with higher tumor burden, compromised hepatic function, and inferior performance status). Recent studies have demonstrated that LR can significantly prolong survival in selected intermediate-advanced stage patients with MHCC. Advancements in minimally invasive techniques, conversion therapy, and comprehensive perioperative management have further expanded surgical indications for MHCC, with survival benefits undergoing qualitative improvements. In the future, the integration of multidisciplinary strategies combining surgical, locoregional, and systemic therapies will be essential for formulating personalized, precision-based, and standardized treatment protocols. Concurrently, progress in evidence-based medicine and technological innovation remains indispensable for optimizing long-term prognosis in patients with MHCC.

1
Bray F, Laversanne M, Sung H, et al. Global Cancer Statistics 2022:GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries[J]. CA Cancer J Clin, 2024, 74(3): 229-263.
2
Viganò L, Costa G, Di Tommaso L. Liver resection for multifocal hepatocellular carcinoma: is it an option?[J]. Hepatobiliary Surg Nutr, 2019, 8(5): 530-533.
3
Forner A, Gilabert M, Bruix J, et al. Treatment of intermediate-stage hepatocellular carcinoma[J]. Nat Rev Clin Oncol, 2014, 11(9): 525-535.
4
Yang Y, Ni Q, Li H, et al. Genomic and the tumor microenvironment heterogeneity in multifocal hepatocellular carcinoma[J]. Hepatology, 2025, 82(3): 582-598.
5
Reig M, Forner A, Rimola J, et al. BCLC strategy for prognosis prediction and treatment recommendation: the 2022 update[J]. J Hepatol, 2022, 76(3): 681-693.
6
European Association for the Study of the Liver. EASL Clinical Practice Guidelines on the management of hepatocellular carcinoma[J]. J Hepatol, 2025, 82(2): 315-374.
7
Singal AG, Llovet JM, Yarchoan M, et al. AASLD Practice Guidance on prevention, diagnosis, and treatment of hepatocellular carcinoma[J]. Hepatology, 2023, 78(6): 1922-1965.
8
Kudo M, Kawamura Y, Hasegawa K, et al. Management of hepatocellular carcinoma in Japan: JSH consensus statements and recommendations 2021 update[J]. Liver Cancer, 2021, 10(3): 181-223.
9
Korean Liver Cancer Association (KLCA) and National Cancer Center (NCC) Korea. 2022 KLCA-NCC Korea practice guidelines for the management of hepatocellular carcinoma[J]. Clin Mol Hepatol, 2022, 28(4): 583-705.
10
中华人民共和国国家卫生健康委员会医政司. 原发性肝癌诊疗指南(2024年版)[J]. 中国实用外科杂志2024, 44(4):361-386.
11
Koh JH, Tan DJH, Ong Y, et al. Liver resection versus liver transplantation for hepatocellular carcinoma within Milan criteria: a meta-analysis of 18,421 patients[J]. Hepatobiliary Surg Nutr, 2022, 11(1): 78-93.
12
Menahem B, Lubrano J, Duvoux C, et al. Liver transplantation versus liver resection for hepatocellular carcinoma in intention to treat: an attempt to perform an ideal meta-analysis[J]. Liver Transpl, 2017, 23(6): 836-844.
13
Jiang L, Yan L, Wen T, et al. Comparison of outcomes of hepatic resection and radiofrequency ablation for hepatocellular carcinoma patients with multifocal tumors meeting the Barcelona-clinic liver cancer stage a classification[J]. J Am Coll Surg, 2015, 221(5): 951-961.
14
Min JH, Kang TW, Cha DI, et al. Radiofrequency ablation versus surgical resection for multiple HCCs meeting the Milan criteria: propensity score analyses of 10-year therapeutic outcomes[J]. Clin Radiol, 2018, 73(7): 676.e15-676.e24.
15
Oh JH, Sinn DH, Choi GS, et al. Comparison of outcome between liver resection, radiofrequency ablation, and transarterial therapy for multiple small hepatocellular carcinoma within the Milan criteria[J]. Ann Surg Treat Res, 2020, 99(4): 238-246.
16
Kawaguchi Y, Hasegawa K, Hagiwara Y, et al. Effect of diameter and number of hepatocellular carcinomas on survival after resection, transarterial chemoembolization, and ablation[J]. Am J Gastroenterol, 2021, 116(8): 1698-1708.
17
Vitale A, Romano P, Cillo U, et al. Liver resection vs nonsurgical treatments for patients with early multinodular hepatocellular carcinoma[J].?JAMA Surg, 2024, 159(8): 881-889.
18
Torzilli G, Belghiti J, Kokudo N, et al. A snapshot of the effective indications and results of surgery for hepatocellular carcinoma in tertiary referral centers: is it adherent to the EASL/AASLD recommendations?:an observational study of the HCC East-West study group[J]. Ann Surg, 2013, 257(5):929-937.
19
Yin L, Li H, Li AJ, et al. Partial hepatectomy vs. transcatheter arterial chemoembolization for resectable multiple hepatocellular carcinoma beyond Milan Criteria: a RCT[J]. J Hepatol, 2014, 61(1): 82-88.
20
Hyun MH, Lee YS, Kim JH, et al. Hepatic resection compared to chemoembolization in intermediate- to advanced-stage hepatocellular carcinoma: a meta-analysis of high-quality studies[J]. Hepatology, 2018, 68(3): 977-993.
21
Sasaki K, Morioka D, Conci S, et al. The tumor burden score: a new "metro-ticket" prognostic tool for colorectal liver metastases based on tumor size and number of tumors[J]. Ann Surg, 2018, 267(1): 132-141.
22
Tsilimigras DI, Moris D, Hyer JM, et al. Hepatocellular carcinoma tumour burden score to stratify prognosis after resection[J]. Br J Surg, 2020, 107(7): 854-864.
23
Tsilimigras DI, Mehta R, Paredes AZ, et al. Overall tumor burden dictates outcomes for patients undergoing resection of multinodular hepatocellular carcinoma beyond the Milan criteria[J]. Ann Surg, 2020, 272(4): 574-581.
24
Akahoshi K, Shindoh J, Tanabe M, et al. Oncological resectability criteria for hepatocellular carcinoma in the era of novel systemic therapies: the Japan Liver Cancer Association and Japanese Society of Hepato-Biliary-Pancreatic Surgery Expert Consensus Statement 2023[J]. Liver Cancer, 2024, 13(6): 0-10.
25
Komatsu S, Tada T, Nishimura T, et al. Prognosis of hepatectomy versus systemic chemotherapy based on oncological resectability criteria for borderline resectable hepatocellular carcinoma[J]. Liver Cancer, Published online June 10, 2025.
26
陈亚峰,李江斌,钟文钧,等. 腹腔镜微波消融治疗≤ 3 cm肝细胞肝癌的临床疗效分析[J/OL]. 中华腔镜外科杂志(电子版), 2021, 14(5): 271-276.
27
Song J, Cao L, Ma K, et al. Laparoscopic liver resection versus radiofrequency ablation for small hepatocellular carcinoma: randomized clinical trial[J]. Br J Surg, 2024, 111(4): znae099.
28
宋华传,季鹏,姚焕章,等. 腹腔镜肝切除术联合微波消融治疗多发性结直肠癌肝转移[J/OL]. 中华腔镜外科杂志(电子版), 2024, 17(4): 222-226.
29
Zhou C, Peng Y, Zhou K, et al. Surgical resection plus radiofrequency ablation for the treatment of multifocal hepatocellular carcinoma[J]. Hepatobiliary Surg Nutr, 2019, 8(1): 19-28.
30
Huang Y, Song J, Zheng J, et al. Comparison of hepatic resection combined with intraoperative radiofrequency ablation, or hepatic resection alone, for hepatocellular carcinoma patients with multifocal tumors meeting the University of California San Francisco (UCSF) criteria: a propensity score-matched analysis[J]. Ann Surg Oncol, 2020, 27(7): 2334-2345.
31
Zheng K, Liao A, Yan L, et al. Hepatic resection combined with intraoperative radiofrequency ablation versus hepatic resection alone for selected patients with moderately advanced multifocal hepatocellular carcinomas[J]. Ann Surg Oncol, 2022, 29(8): 5189-5201.
32
Peng Y, Liu F, Xu H, et al. Outcomes of laparoscopic liver resection for patients with multiple hepatocellular carcinomas meeting the Milan criteria: a propensity score-matched analysis[J]. J Laparoendosc Adv Surg Tech A, 2019, 29(9): 1144-1151.
33
Peng Y, Chen K, Li B, et al. Laparoscopic versus open liver resection for resectable HCC with BCLC stage B: a propensity score-matched analysis[J]. Updates Surg, 2022, 74(4): 1291-1297.
34
Lu Shiliu, Yuan Guandou, Lei Biao, et al. Application of da Vinci surgery in hepatectomy[J]. Intelligent Surgery, 2022, 5: 6-11.
35
中国抗癌协会肝癌专业委员会转化治疗协作组. 原发性肝癌转化及围手术期治疗中国专家共识(2024版)[J]. 中华消化外科杂志2024, 23(4): 492-513.
36
Guiu B, Chevallier P, Denys A, et al. Simultaneous trans-hepatic portal and hepatic vein embolization before major hepatectomy: the liver venous deprivation technique[J]. Eur Radiol, 2016, 26(12): 4259-4267.
37
侯昌龙,王继洲,宋瑞鹏,等. 术前肝静脉剥夺术同期联合精准肝动脉化疗栓塞在原发性大肝癌二期切除中应用价值研究[J]. 中国实用外科杂志2022, 42(6):667-671.
38
Zhang S, Song R, Hou C, et al. Simultaneous liver venous deprivation following hepatic arterial chemoembolization before major hepatectomy for hepatocellular carcinoma: a new methods to achieve hypertrophy liver remnant[J]. J Hepatocell Carcinoma, 2025, 12: 219-229.
39
Chen Y, Zhang J, Hu W, et al. Envafolimab plus lenvatinib and transcatheter arterial chemoembolization for unresectable hepatocellular carcinoma: a prospective, single-arm, phase II study[J]. Signal Transduct Target Ther, 2024, 9(1): 280.
40
Yunfei Y, Jiliang Q, Zhenkun H, et al. PD-1 inhibitor (sintilimab) and lenvatinib plus TACE-HAIC as conversion therapy for initially unresectable HCC: a single-arm, phase 2 clinical trial (PLATIC)[J]. J Clin Oncol, 2024, 42(Suppl 16): 4123-4123.
41
Wu JY, Wu JY, Fu YK, et al. Outcomes of salvage surgery versus non-salvage surgery for initially unresectable hepatocellular carcinoma after conversion therapy with transcatheter arterial chemoembolization combined with lenvatinib plus Anti-PD-1 antibody: a multicenter retrospective study[J]. Ann Surg Oncol, 2024, 31(5): 3073-3083.
42
Sangro B, Kudo M, Erinjeri JP, et al. Durvalumab with or without bevacizumab with transarterial chemoembolisation in hepatocellular carcinoma (EMERALD-1): a multiregional, randomised, double-blind, placebo-controlled, phase 3 study[J]. Lancet, 2025, 405(10474): 216-232.
43
Kudo M, Ren Z, Guo Y, et al. Transarterial chemoembolisation combined with lenvatinib plus pembrolizumab versus dual placebo for unresectable, non-metastatic hepatocellular carcinoma (LEAP-012): a multicentre, randomised, double-blind, phase 3 study[J]. Lancet, 2025, 405(10474): 203-215.
44
Dong Jiahong, Han Guohong, Ogasawara R, et al. LBA2 TALENTACE: a phase III, open-label, randomized study of on-demand transarterial chemoembolization (TACE) combined with atezolizumab + bevacizumab (Atezo+Bev) or on-demand TACE alone in patients with systemically untreated, intermediate-to-high burden unresectable hepatocellular carcinoma (uHCC)[J]. Annals of Oncology, 2025, 36(Suppl 1): S62.
45
Wei W, Li SH, Zhao RC, et al. Neoadjuvant hepatic arterial infusion chemotherapy with FOLFOX could improve outcomes of resectable BCLC stage A/B hepatocellular carcinoma patients beyond Milan criteria: a multi-center, phase 3, randomized, controlled clinical trial[J]. J Clin Oncol, 2023, 41(Suppl 16): 4023.
46
Wu JY, Wu JY, Li YN, et al. Lenvatinib combined with anti-PD-1 antibodies plus transcatheter arterial chemoembolization for neoadjuvant treatment of resectable hepatocellular carcinoma with high risk of recurrence: a multicenter retrospective study[J]. Front Oncol, 2022, 12: 985380.
47
Qin S, Chen M, Cheng AL, et al. Atezolizumab plus bevacizumab versus active surveillance in patients with resected or ablated high-risk hepatocellular carcinoma (IMbrave050): a randomised, open-label, multicentre, phase 3 trial[J]. Lancet, 2023, 402(10415): 1835-1847.
48
Yopp A, Kudo M, Chen M, et al. LBA39-Updated efficacy and safety data from IMbrave050: Phase III study of adjuvant atezolizumab (atezo) + bevacizumab (bev) vs active surveillance in patients (pts) with resected or ablated high-risk hepatocellular carcinoma (HCC)[J]. Annals of Oncology, 2024, 35: 1-72.
49
Wang Z, Fan J, Zhou S, et al. Perioperative camrelizumab plus rivoceranib versus surgery alone in patients with resectable hepatocellular carcinoma at intermediate or high risk of recurrence (CARES-009): a randomised phase 2/3 trial[J]. Lancet, 2025, 406(10515): 2089-2099.
50
Duininck G, Lopez-Aguiar AG, Lee RM, et al. Optimizing cancer care for hepatocellular carcinoma at a safety-net hospital: The value of a multidisciplinary disease management team[J]. J Surg Oncol, 2019, 120(8): 1365-1370.
60
Sinn DH, Choi GS, Park HC, et al. Multidisciplinary approach is associated with improved survival of hepatocellular carcinoma patients[J]. PLoS One, 2019, 14(1): e0210730.
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