肝癌分哪几种类型，诊疗上有何区别?｜ElephanTalk
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;">肝癌分哪几种类型，诊疗上有何区别</strong></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;"><span style="color: black;">人们<span style="color: black;">一般</span>所说的 “肝癌”，<span style="color: black;">指的是</span>原发于肝脏的恶性肿瘤，即原发性肝癌。</span></strong><span style="color: black;">出现</span>于其他器官而转移至肝脏的恶性肿瘤则<span style="color: black;">叫作</span>为“继发性肝癌”，<span style="color: black;">这里</span>不做讨论。</p><img src="https://mmbiz.qpic.cn/mmbiz_png/lQzXWpmM34WJSfADD6Qhla29n9oxbR6HMiaAPia1H8GUrkKz9rFIEX3N0LJFatv0tl7uAONqoj5OawYj2ibCicZiaiaw/640?wx_fmt=png&from=appmsg&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;">
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">临床上，经常有<span style="color: black;">病人</span>提出疑问：“都是肝癌，<span style="color: black;">为何</span>我的<span style="color: black;">检测</span>项目和治疗<span style="color: black;">方法</span>跟别人不<span style="color: black;">同样</span>呢？”</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">其实，原发性肝癌<span style="color: black;">按照</span>显微镜下的形态差异，<span style="color: black;">或</span>说<span style="color: black;">按照</span>肿瘤起源细胞的不同分为<strong style="color: blue;"><span style="color: black;">3种类型：肝细胞癌、肝内胆管癌和混合型肝细胞癌-胆管癌</span></strong>。三者在发病机制、生物学<span style="color: black;">行径</span>、病理组织学、诊疗<span style="color: black;">办法</span>等方面差异<span style="color: black;">很强</span>。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;">肝脏的生理功能及</strong><strong style="color: blue;">其组织学<span style="color: black;">形成</span></strong></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">肝脏是人体最大的消化腺体。肝细胞<span style="color: black;">每日</span>能产生600~1000毫升胆汁，<span style="color: black;">做为</span><strong style="color: blue;"><span style="color: black;">消化液参与脂类<span style="color: black;">食品</span>的消化；肝合成多种蛋白质等多类物质，<span style="color: black;">同期</span>还参与糖、脂类、激素和<span style="color: black;">药品</span>的代谢与解毒。</span></strong>
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<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">显微镜下，成千上万个肝细胞<span style="color: black;">形成</span>1个肝小叶，<span style="color: black;">做为</span>肝脏的基本结构单位，成人肝<span style="color: black;">大概</span>50万~100万个肝小叶。在肝小叶中央以及周边还有许多微型脉管和血窦等结构，可为肝细胞<span style="color: black;">供给</span>营养，<span style="color: black;">同期</span>将各类物质<span style="color: black;">传送</span>至肝细胞进行代谢；<span style="color: black;">同期</span>，肝细胞周边有许多微细的<span style="color: black;">胆怯</span>管，这些微小的脉管和胆管逐级汇合，<span style="color: black;">最后</span>形成粗大的管道（门静脉、动脉、胆管）由肝门进出肝脏，肝细胞分泌的胆汁<span style="color: black;">最后</span>经胆总管流入肠道参与消化，<span style="color: black;">或</span>进入胆囊储存起来。<span style="color: black;">能够</span>把肝脏比喻成一棵枝繁叶茂的 “大树”：把肝细胞<span style="color: black;">或</span>肝小叶想象成树叶，将肝细胞间的各类脉管、血窦以及<span style="color: black;">胆怯</span>管想象成树叶上的经络，这些细枝末节层层递进，逐级汇合成更大的树枝，众多粗壮的树枝<span style="color: black;">最后</span>形<span style="color: black;">成为了</span>树干。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">从<strong style="color: blue;"><span style="color: black;"><span style="color: black;">出现</span>部位</span></strong>来区分3种类型的肝瘤：<span style="color: black;">肝细胞癌<span style="color: black;">出现</span>于“树叶”，肝内胆管癌则<span style="color: black;">出现</span>于树叶间的经络<span style="color: black;">或</span>细小的树枝，而混合型肝癌则<span style="color: black;">出现</span>于树叶与树枝交汇处，</span>是<span style="color: black;">拥有</span>2种<span style="color: black;">成份</span>的癌变，<span style="color: black;">同期</span>具备这2种肿瘤的生物学特征。<span style="color: black;">因此呢</span>，本文<span style="color: black;">针对</span>混合型肝癌，<span style="color: black;">再也不</span>单独<span style="color: black;">陈列</span>比较。接下来来<span style="color: black;">瞧瞧</span>肝细胞癌与肝内胆管癌两者在<strong style="color: blue;"><span style="color: black;">发病危险<span style="color: black;">原因</span>、血清学标志物、临床表现、诊疗模式等方面</span></strong>的不同。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;">1</strong></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">危险<span style="color: black;">原因</span></strong></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">肝细胞癌</strong></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;"><span style="color: black;">在我国 80%的肝细胞癌与病毒性肝炎感染<span style="color: black;">相关</span></span></strong><strong style="color: blue;"><span style="color: black;">，</span></strong><span style="color: black;">包含</span>乙肝和丙肝的感染。其他的高危<span style="color: black;">原因</span>还<span style="color: black;">包含</span>过度饮酒、非酒精性脂肪肝、其他<span style="color: black;">原由</span><span style="color: black;">导致</span>的肝硬化，如血吸虫性肝硬化等。</p><img src="https://mmbiz.qpic.cn/mmbiz_png/lQzXWpmM34WJSfADD6Qhla29n9oxbR6H8Jk5UEiaJRxW6vfVibeiaibIuEOINKKgBjiaYhHgyiarYQbWNlJhjIL6oRWQ/640?wx_fmt=png&from=appmsg&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;">
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">肝内胆癌</strong></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">高龄、胆管结石、胆管腺瘤、胆管乳头状瘤病、胆总管囊肿 、病毒性肝炎、肝硬化、原发性硬化性胆管炎、溃疡性结肠炎、化学毒素、吸烟、寄生虫<span style="color: black;">引起</span>胆管上皮<span style="color: black;">损害</span>、胆汁淤积<span style="color: black;">引起</span>的慢性炎症等。<span style="color: black;">另外</span>，代谢综合症（<span style="color: black;">包含</span><span style="color: black;">肥壮</span>症、糖尿病和非酒精性脂肪肝），过量饮酒，病毒性肝炎等<span style="color: black;">亦</span>与肝内胆管癌的<span style="color: black;">出现</span>密切<span style="color: black;">关联</span>。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;">2</strong></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;">血清学标志物</strong></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">肝细胞癌</strong></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">血清甲胎蛋白（AFP）、<span style="color: black;">反常</span>凝血酶原、<span style="color: black;">血液</span>游离微 RNA、血清甲胎蛋白<span style="color: black;">控制</span>体（AFP-L3）都可<span style="color: black;">做为</span>肝癌<span style="color: black;">初期</span>诊断的血清学标志物。</p>
<img src="https://mmbiz.qpic.cn/mmbiz_svg/PL5y7QQHZgKrAY7ibNPRCRJaeAKu5ibalOu1XHL6KnTIoxPtEmrsPTc3hicFGhPoEkgLiaficiaPrIFl3He8Aan5VRYJm0DGL4fQYp/640?wx_fmt=svg&from=appmsg&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;">
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">肝内胆管癌</strong></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">糖类抗原 199 (CA199)、癌胚抗原 (CEA）是<strong style="color: blue;"><span style="color: black;">诊断肝内胆管癌最常用的血清学标志物。</span></strong></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;">3</strong></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;">临床表现</strong></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">3种类型的肝癌在<span style="color: black;">疾患</span>的<span style="color: black;">初期</span><span style="color: black;">一般</span><span style="color: black;">无</span><span style="color: black;">显著</span>症状，大<span style="color: black;">都数</span><span style="color: black;">病人</span>是在体检中<span style="color: black;">发掘</span>的。<strong style="color: blue;"><span style="color: black;">值得一提的是，肝细胞癌<span style="color: black;">由于</span>常合并乙肝肝硬化，<span style="color: black;">初期</span><span style="color: black;">亦</span>可<span style="color: black;">显现</span>与肝硬化<span style="color: black;">关联</span>的症状及体征，</span></strong>如腹水、肝掌、蜘蛛痣以及食管胃底静脉曲张<span style="color: black;">导致</span>的呕血等。<span style="color: black;">疾患</span><span style="color: black;">发展</span>至晚期，<span style="color: black;">因为</span>肿瘤消耗可<span style="color: black;">显现</span>营养不良、消瘦等全身症状，肝内胆管癌<span style="color: black;">因为</span><span style="color: black;">出现</span>在 “树枝”<span style="color: black;">这般</span>的脉管结构，在晚期若侵犯更大的“树枝”或“树干”，影响了胆汁的排泄时，则会<span style="color: black;">显现</span>黄疸症状。</p><img src="https://mmbiz.qpic.cn/mmbiz_png/lQzXWpmM34WJSfADD6Qhla29n9oxbR6HVxtt04Ld6jFM0sPQzKrJLCwQe4HTEh7Eg2r7dvpDJ4nlX82toOWkPw/640?wx_fmt=png&from=appmsg&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;">
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;">4</strong></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;">诊疗模式</strong></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">手术前<span style="color: black;">检测</span></strong></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">除了常规的心肺功能、腹部超声、上腹部<span style="color: black;">加强</span>磁共振外，临床上疑似肝内胆管癌的<span style="color: black;">病人</span><span style="color: black;">一般</span>需完善正电子发射计算机断层扫描(PET-CT）全身肿瘤筛查。这是<span style="color: black;">由于</span>肝内胆管癌恶性程度更高，<span style="color: black;">初期</span>易<span style="color: black;">出现</span>淋巴结或远处转移，<strong style="color: blue;"><span style="color: black;"><span style="color: black;">因此呢</span>术前的全身筛查结果将直接影响接下来的治疗方式。</span></strong></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;"><span style="color: black;">手术治疗</span></strong></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">不论是哪种类型的肝癌，<strong style="color: blue;"><span style="color: black;">根治性手术切除都是<span style="color: black;">日前</span>首选治疗方式。</span></strong>
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<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">不同的是，<span style="color: black;">因为</span>肝内胆管癌淋巴结转移概率高，手术中需常规进行肝门区域的淋巴结清扫。</p>
<img src="data:image/svg+xml,%3C%3Fxml version=1.0 encoding=UTF-8%3F%3E%3Csvg width=1px height=1px viewBox=0 0 1 1 version=1.1 xmlns=http://www.w3.org/2000/svg xmlns:xlink=http://www.w3.org/1999/xlink%3E%3Ctitle%3E%3C/title%3E%3Cg stroke=none stroke-width=1 fill=none fill-rule=evenodd fill-opacity=0%3E%3Cg transform=translate(-249.000000, -126.000000) fill=%23FFFFFF%3E%3Crect x=249 y=126 width=1 height=1%3E%3C/rect%3E%3C/g%3E%3C/g%3E%3C/svg%3E" style="width: 50%; margin-bottom: 20px;">
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;"><span style="color: black;">非手术治疗</span></strong></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">针对</span><span style="color: black;">没</span>法接受手术的<span style="color: black;">病人</span>，可采取<span style="color: black;">包含</span><strong style="color: blue;"><span style="color: black;">局部治疗和系统治疗</span></strong>的<span style="color: black;">办法</span>。</p><img src="https://mmbiz.qpic.cn/mmbiz_png/lQzXWpmM34WJSfADD6Qhla29n9oxbR6HgdYMH4340cvLtEI22K1SyAeja8BmV2Wrr9I96ibJYjb63icX3TJpwtPA/640?wx_fmt=png&from=appmsg&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;">
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;"><span style="color: black;">局部治疗</span></strong>：临床上<span style="color: black;">平常</span>的局部治疗<span style="color: black;">办法</span><span style="color: black;">包含</span>经动脉导管化疗栓塞（TACE )、射频或微波消融治疗、放射治疗等。TACE <span style="color: black;">便是</span>临床上常说的介入治疗，它是一种<span style="color: black;">经过</span>导管将抗肿瘤化疗<span style="color: black;">药品</span>注入肝动脉的肿瘤供血分支来杀伤肿瘤细胞的治疗<span style="color: black;">办法</span>。相<span style="color: black;">针对</span>肝细胞癌，肝内胆管癌的动脉血供不丰富，TACE 难以达到理想的效果。<span style="color: black;">因此呢</span>，临床上肝内胆管癌的<span style="color: black;">病人</span>很少采用介入治疗，而<strong style="color: blue;"><span style="color: black;">在肝细胞癌<span style="color: black;">病人</span><span style="color: black;">中间商</span>入治疗更为<span style="color: black;">平常</span>。</span></strong></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;"><span style="color: black;">系统治疗</span></strong>：系统治疗<span style="color: black;">亦</span><span style="color: black;">便是</span>人们常说的化疗、免疫治疗以及靶向治疗。值得一提的是，肝细胞癌对化疗不<span style="color: black;">敏锐</span>，<span style="color: black;">因此呢</span>不<span style="color: black;">做为</span>一线首选治疗<span style="color: black;">方法</span>。反之，以吉西他滨联合铂类为主的化疗<span style="color: black;">方法</span>对肝内胆管癌有不错的效果。<strong style="color: blue;"><span style="color: black;">而</span></strong><strong style="color: blue;"><span style="color: black;">不论哪一类型的肝癌，免疫或靶向治疗都已越居不可切除肝癌<span style="color: black;">药品</span>治疗的一线<span style="color: black;">方法</span>。</span></strong></p><img src="https://mmbiz.qpic.cn/mmbiz_png/lQzXWpmM34WJSfADD6Qhla29n9oxbR6HScGcJsmWSq9BFdroFmfVlM76wpjQEuZvytNTdXhGjEk6gzvnLtoS5A/640?wx_fmt=png&from=appmsg&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;">
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