360.4 📋 章末速蚘 Summary

360.4.1 🔑 䞀句話瞜結

HCC = 6th most common cancer worldwide + 3rd leading cancer death; ~ 90% in cirrhotic liver; risk factors HBV (top globally) + HCV (declining with DAAs) + ALD + MASLD/MASH (rising) + aflatoxin + hemochromatosis; 台灣 HBV-related historically declining with vaccination, MASLD/MASH rising; surveillance abdominal US ± AFP every 6 months for cirrhotic any cause + HBV high-risk non-cirrhotic; diagnosis LI-RADS LR-5 (arterial enhancement + portal venous washout + capsule appearance) — no biopsy needed; BCLC staging integrates tumor + liver function + PS — 0/A early (resection, ablation, transplant Milan criteria single ≀ 5 cm OR ≀ 3 ≀ 3 cm), B intermediate (TACE conventional or DEB), C advanced (systemic), D terminal; HCC first-line advanced systemic — atezolizumab + bevacizumab (IMbrave150, NEJM 2020, OS 19.2 mo) preferred + durvalumab + tremelimumab STRIDE (HIMALAYA, NEJM 2022) alternative + sorafenib (SHARP) + lenvatinib (REFLECT); second-line regorafenib (RESORCE) + cabozantinib (CELESTIAL) + ramucirumab (REACH-2 AFP > 400) + nivolumab; Cholangiocarcinoma (CCA) intrahepatic (iCCA, rising) + perihilar (Klatskin) + distal; risk factors PSC (top in Western) + hepatolithiasis + liver flukes (Opisthorchis, Clonorchis — Asia) + biliary cysts; TOPAZ-1 (NEJM 2022) durvalumab + cis/gem first-line new SOC; targeted therapy second-line — pemigatinib (FGFR2 fusion, 10-15% iCCA) + futibatinib (FGFR2) + ivosidenib (IDH1 mutation, 15-20% iCCA) + dabrafenib+trametinib (BRAF V600E) + trastuzumab (HER2); Mayo Protocol = LT for early hilar CCA with neoadjuvant chemoradiation (5-yr 65%); GIST KIT/PDGFRA → imatinib + sunitinib + regorafenib + ripretinib + avapritinib; NET somatostatin analogs + everolimus + sunitinib + PRRT (177Lu-DOTATATE)。

360.4.2 💊 治療粟芁

  • HCC BCLC 0/Aresection (non-cirrhotic preferred), ablation RFA/MWA ≀ 3 cm, transplant Milan criteria
  • HCC BCLC BTACE conventional (lipiodol + doxorubicin) or DEB-TACE; alternative TARE (Y-90 microspheres)
  • HCC BCLC C first-lineatezolizumab + bevacizumab (IMbrave150) preferred → EGD before bev for variceal screening
  • HCC BCLC C alternative first-linedurvalumab + tremelimumab (HIMALAYA STRIDE) if varices/CV risk → no bevacizumab
  • HCC BCLC C if IO contraindicatedsorafenib or lenvatinib TKI
  • HCC second-lineregorafenib (RESORCE post-sorafenib) + cabozantinib (CELESTIAL) + ramucirumab (REACH-2 AFP > 400)
  • CCA first-line advancedcisplatin + gemcitabine + durvalumab (TOPAZ-1, NEJM 2022) new SOC
  • CCA targeted second-linepemigatinib (FGFR2 fusion) + futibatinib (FGFR2) + ivosidenib (IDH1) + dabrafenib+trametinib (BRAF V600E) + trastuzumab (HER2)
  • CCA adjuvant resectedcapecitabine (BILCAP) for 6 months
  • Mayo Protocol hilar CCAneoadjuvant chemoradiation + LT
  • GISTimatinib 400 mg/d (KIT/PDGFRA) first-line; sunitinib → regorafenib → ripretinib → avapritinib (PDGFRA D842V)
  • NEToctreotide LAR or lanreotide; everolimus (RADIANT-4); sunitinib (pNET); PRRT 177Lu-DOTATATE (NETTER-1)

360.4.3 🎯 盧醫垫的考前提醒

  1. HCC surveillance: abdominal ultrasound ± AFP every 6 months for cirrhotic any cause + HBV high-risk non-cirrhotic (Asian male > 40, Asian female > 50, African > 20, family history)
  2. LI-RADS LR-5 = definitively HCC: arterial enhancement + portal venous/delayed washout + capsule appearance on multiphase CT/MRI — no biopsy needed; biopsy only atypical
  3. BCLC staging integrates tumor burden + liver function + performance status: 0/A early (curative) + B intermediate (TACE) + C advanced (systemic) + D terminal (supportive)
  4. Milan criteria for HCC transplant (memorize): single ≀ 5 cm OR ≀ 3 nodules each ≀ 3 cm, no vascular invasion, no extrahepatic spread
  5. HCC first-line advanced: atezolizumab + bevacizumab (IMbrave150, NEJM 2020) preferred → EGD before bev for variceal screening; durvalumab + tremelimumab STRIDE (HIMALAYA, NEJM 2022) alternative if varices/CV risk
  6. HCC second-line: regorafenib (RESORCE) + cabozantinib (CELESTIAL) + ramucirumab (REACH-2 if AFP > 400) + nivolumab
  7. Cholangiocarcinoma risk factors: PSC (top Western) + hepatolithiasis + liver flukes Opisthorchis/Clonorchis (Asia) + biliary cysts + chronic hepatitis
  8. CCA first-line: cisplatin + gemcitabine + durvalumab (TOPAZ-1, NEJM 2022) new SOC replaces ABC-02 cis/gem
  9. CCA targeted therapy: pemigatinib FGFR2 fusion (10-15% iCCA, FDA 2020) + ivosidenib IDH1 mutation (15-20% iCCA, FDA 2021) — test molecular before targeted therapy
  10. Mayo Protocol for hilar cholangiocarcinoma = early stage CCA + neoadjuvant chemoradiation + liver transplant; GIST → imatinib (KIT/PDGFRA); carcinoid syndrome (flushing + diarrhea + right heart valve) → octreotide