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肝癌局部治疗策略
DOI: 10.12449/JCH250804
利益冲突声明：本文不存在任何利益冲突。
作者贡献声明：向华文章总体设计与构思；对全文进行最终审核；龙林、张永琎、赵杨、李慕梓参与文章的概念构思，对全文进行多次修订、润色与校对；周菊梅、刘韧耕、石世雄、王蓉蓉协助进行文献检索，参与部分章节的撰写工作。
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摘要: 原发性肝癌在我国发病率与死亡率居高不下，因多数患者确诊时已属晚期，外科手术适用受限。本文通过综述现有常用及先进的肝癌局部治疗技术，全面整合局部消融（射频消融、微波消融、不可逆电穿孔和冷冻消融等）、血管内介入（经导管动脉栓塞化疗、肝动脉灌注化疗和钇-90放射栓塞）及放疗（射波刀、质子治疗、重离子治疗）等主流技术进展，通过对比各项治疗技术的治疗原理、适应证与局限性、临床数据等，构建基于多维度的肝癌局部治疗决策框架。本文旨在为目前仍存在的临床决策困境提供循证依据，推动局部治疗在临床实践中的角色升级，并提出未来研究与实践的变革方向。本文旨在为肝癌局部治疗绘制的一张临床路线图，既解决“当前如何选技术”的实践问题，更指引“未来往何处突破”的研究方向，目的是通过技术整合与模式创新，重塑肝癌治疗格局。Abstract: The incidence and mortality rates of hepatocellular carcinoma （HCC） remain high in China， and the application of surgical resection is often limited due to the fact that most patients are in the advanced stage at the time of confirmed diagnosis. This article reviews commonly used advanced locoregional therapies for HCC and the advances in mainstream techniques such as local ablation （radiofrequency ablation， microwave ablation， irreversible electroporation， and cryoablation）， intravascular intervention （transcatheter arterial chemoembolization， hepatic arterial infusion chemotherapy， and Y90 hepatic arterial infusion chemotherapy）， and radiotherapy （CyberKnife， proton therapy， and heavy-ion therapy）， and a multidimensional decision-making framework is constructed for HCC locoregional therapy by comparing treatment principles， indications， limitations， and clinical data of these techniques. This article aims to provide evidence-based support for persistent dilemmas in clinical decision-making， promote the role of locoregional therapies in clinical practice， and propose the directions for future research and clinical application. This article also establishes a comprehensive clinical roadmap for HCC locoregional therapy， which helps to address current challenges regarding technique selection and delineate future directions for innovation， in order to reshape the treatment of HCC through technological integration and paradigm innovation.
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Key words:
- Liver Neoplasms /
- Antineoplastic Protocols /
- Precision Medicine
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表 1 局部消融治疗技术的比较
Table 1. Comparison of local ablation treatment techniques
技术名称 核心原理 适用人群/病灶特征 优势 局限性 RFA 高频交流电（400～900 kHz）
通过电极针产生焦耳热，使
组织温度>60 ℃致凝固坏死≤3 cm小肝癌，尤其远离
大血管微创、成本低、5年生存率
40%～70%热沉效应明显；单点消融直
径≤3 cm；组织碳化限制能
量扩散MWA 微波电磁场（915/2 450 MHz）
驱动水分子旋转生热，快速升
温至60～150 ℃致凝固坏死>3 cm肝癌、富血供肿瘤，
邻近大血管（如肝门区）穿透深（>5 cm），抗热沉效应强，
消融时间比RFA缩短30%～
50%成本较高；需规避金属植入
物（如心脏起搏器）IRE 高压脉冲电场在细胞膜上形
成永久性微孔，非热性破坏细
胞稳态肿瘤紧邻血管、胆管、膈
肌、肝门、胃肠道等危险
部位非热消融、选择性杀伤肿瘤细
胞、保护血管/胆管结构操作复杂、成本高、肿瘤大
小受限、并发症风险较高CRA 重复冷冻和复温的过程对组
织产生即时物理性损伤；冷冻
引起微血管收缩、血栓形成导
致微循环进行性衰竭；肿瘤微
环境的改变和肿瘤的坏死及
凋亡可激活抗肿瘤免疫反应位置特殊、临近高风险部
位的体积相对较小的肝癌术中疼痛轻；激活抗肿瘤免疫
应答（T细胞活化、远隔效应）；
冰球可视化（CT/MRI实时监测）消融效率与RFA、MWA相
当，但操作稍复杂PEI 无水酒精致肿瘤细胞脱水、蛋
白变性及坏死高风险部位（如紧贴重要
结构）；辅助热消融治疗无热损伤、安全性高、对周围组
织损伤小需多点、多次穿刺；药物弥
散不均；单用效率低
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