CPG มะเร็งตับและท่อน้ำดี

·π«∑“ß°“√µ√«®«π‘ ®‘ ©¬— ·≈–√—°…“
‚√§¡–‡√ßÁ µ—∫·≈–¡–‡√Áß∑àÕπÈ”¥’

∫√√≥“∏°‘ “√

Õ“§¡ ™¬— «’√–«≤— π– ‡ “«§π∏å »°ÿ √‚¬∏π‘

Õ“§¡ ‡™¬’ √»‘≈ªá ∏√’ «≤ÿ ‘ §ŸÀ–‡ª√¡–

 ∂“∫—π¡–‡√ßÁ ·Ààß™“µ‘

°√¡°“√·æ∑¬å °√–∑√«ß “∏“√≥ ¢ÿ

™ÕË◊ Àπß—  Õ◊ : ·π«∑“ß°“√µ√«®«π‘ ®‘ ©¬— ·≈–√°— …“‚√§¡–‡√ßÁ µ∫— ·≈–¡–‡√ßÁ ∑Õà π”È ¥’

ISBN : 974-9770-95-1

ª∑ï Ë’æ‘¡æå : æ‘¡æ§å √—Èß∑Ë’ 1 æ.». 2549 ®”π«π 1,000 ‡≈¡à

æ¡‘ æ∑å ’Ë : ™ÿ¡πÿ¡ À°√≥°å “√‡°…µ√·Ààߪ√–‡∑»‰∑¬

 ∂“π∑’µË ¥‘ µàÕ : °≈ÿ¡à ß“π π—∫ πÿπ«™‘ “°“√
 ∂“∫π— ¡–‡√Áß·Àßà ™“µ‘ °√¡°“√·æ∑¬å °√–∑√«ß “∏“√≥ ÿ¢
268/1 ∂ππæ√–√“¡∑’Ë 6 ‡¢µ√“™‡∑«’ °√ßÿ ‡∑æœ 10400
‚∑√»—æ∑å : 0-2354-7025 µÕà 2205
‚∑√ “√ : 0-2644-9097

 “√∫—≠ Àπ“â
1
● ™π‘¥¢Õߧ”·π–π” (Categories of Consensus)
● ¡–‡√ßÁ µ∫— (Hepatocellular Carcinoma) 3

◆ ·ºπ¿¡Ÿ ‘· ¥ß¢—πÈ µÕπ°“√¥·Ÿ ≈√°— …“¡–‡√ßÁ µ—∫ 4
◆ ·π«∑“ß°“√µ√«®§—¥°√Õß «‘π‘®©—¬·≈–√—°…“ºªŸâ É«¬¡–‡√ßÁ µ∫— 8
◆ ·π«∑“ß„π°“√√—°…“¡–‡√ßÁ µ∫— ·≈–°“√µ√«®µ¥‘ µ“¡ 16
◆ ·π«∑“ß°“√„™√â ß—  √’ °— …“„π¡–‡√ßÁ µ—∫ 24
◆ ·π«∑“ß°“√®—¥√–¬–‚√§¡–‡√Áßµ—∫ 27

● ¡–‡√Áß∑àÕπÈ”¥’ (Cholangiocarcinoma) 31

◆ ·ºπ¿Ÿ¡‘· ¥ß·π«∑“ß°“√¥Ÿ·≈√—°…“¡–‡√Áß∑Õà π”È ¥’ 32
◆ ·π«∑“ß°“√µ√«®§¥— °√Õß·≈–«‘π®‘ ©¬— ¡–‡√Áß∑àÕπÈ”¥’ 35
◆ ·π«∑“ß°“√√—°…“·≈–µ√«®µ¥‘ µ“¡¡–‡√ßÁ ∑Õà πÈ”¥’ 45
◆ ·π«∑“ß°“√√—°…“¡–‡√ßÁ ∑àÕπÈ”¥’º“à π°≈âÕß Õà ßµ√«®∑àÕπ”È ¥·’ ≈–µ∫— ÕàÕπ 56
◆ ·π«∑“ß°“√√°— …“¥â«¬‡§¡∫’ ”∫¥— „π¡–‡√ßÁ ∑àÕπÈ”¥’ 63
◆ ·π«∑“ß°“√„™√â ß—  √’ °— …“„π¡–‡√Áß∑Õà π”È ¥’ 72
◆ ·π«∑“ß°“√®—¥√–¬–‚√§¡–‡√ßÁ ∑àÕπ”È ¥’ 75

● °“√µ√«®∑“ß欓∏«‘ ∑‘ ¬“¢Õ߇´≈≈·å ≈–™πÈ‘ ‡πÕÈ◊ ¡–‡√Áßµ∫— ·≈–¡–‡√ßÁ ∑àÕπ”È ¥’ 79

◆ ·ºπ¿¡Ÿ ‘·π«∑“ß°“√‡µ√’¬¡·≈–°“√«‘π®‘ ©¬— ∑“߇´≈≈å欓∏«‘ ∑‘ ¬“ 80
◆ ·π«∑“ß°“√«‘π‘®©—¬¡–‡√ßÁ µ∫— ·≈–¡–‡√ßÁ ∑Õà π”È ¥’®“° ‘Ë߇®“–¥¥Ÿ 82
◆ ·ºπ¿Ÿ¡·‘ π«∑“ß°“√‡µ√’¬¡·≈–°“√«π‘ ®‘ ©¬— ∑“߇πÈ◊Õ‡¬Ë◊Õ欓∏‘«‘∑¬“ 87
◆ ·π«∑“ß°“√µ√«®™‘Èπ‡πÈ◊Õº“à µ¥— ®“°µ—∫ 89
◆ ·π«∑“ß°“√√“¬ß“π °“√«‘π®‘ ©—¬¡–‡√Áßµ∫— ª∞¡¿¡Ÿ ®‘ “°™π‘È ‡πÕ◊È 96

● ∫∑∫“∑√—ß «’ ‘π®‘ ©¬— ·≈–√ß—  √’ «à ¡√—°…“°∫— ¡–‡√ßÁ µ∫— ·≈–¡–‡√ßÁ ∑àÕπÈ”¥’ 102
111
● ¿“§ºπ«°
112
◆ Childûs Classification 113
◆ Performance status 114
◆ ¢È—πµÕπ°“√¥”‡π‘πß“π®—¥∑”·π«∑“ß°“√µ√«®«‘π‘®©—¬·≈–
115
√°— …“‚√§¡–‡√ßÁ µ∫— ·≈–¡–‡√ßÁ ∑àÕπÈ”¥’

● √“¬π“¡§≥–º®âŸ ¥— ∑”Àπß—  ◊Õ·π«∑“ß°“√µ√«®«π‘ ®‘ ©¬— ·≈–√—°…“¡–‡√ßÁ µ∫—
·≈–¡–‡√ßÁ ∑Õà π”È ¥’

¢

§”π”

¡–‡√Áßµ—∫‡ªìπ¡–‡√Áß∑Ë’æ∫¡“°‡ªìπÕ—π¥—∫Àπ÷Ëß ·≈–‡ªìπÀπË÷ß„π‚√§¡–‡√Áß∑’ËÕ¬Ÿà„π·ºπ°“√
ªÕÑ ß°—π·≈–§«∫§ÿ¡‚√§¡–‡√ÁߢÕߪ√–‡∑»‰∑¬ (National Cancer Control Program) ¥—ßπÈ—π ‡æ◊ËÕ„À¡â ’
·π«∑“ß°“√µ√«®«‘π‘®©—¬·≈–√—°…“∑’ˇÀ¡“– ¡  ”À√—∫ºâŸªÉ«¬„πª√–‡∑»‰∑¬ ‚¥¬‰¥â√—∫§«“¡√à«¡¡◊Õ
®“°ºâŸ‡™Ë’¬«™“≠·≈–ºâŸ∑√ߧÿ≥«ÿ≤‘∑“ߥâ“π‚√§¡–‡√Áßµ—∫ À≈“¬ “¢“¡“√à«¡ª√–™ÿ¡®—¥∑”·π«∑“ß
°“√µ√«®«‘π‘®©—¬·≈–√—°…“‚√§¡–‡√Áßµ—∫ ·≈–¡–‡√Áß∑àÕπ”È ¥’ ´Ë÷߇ªìπ·π«∑“ß∑Ë’®–„ÀâºâŸªÉ«¬‚√§¡–‡√Áßµ—∫
‰¥â√∫— ª√–‚¬™π å Ÿß ¥ÿ ‚¥¬‰¡¡à ’§«“¡ª√– ß§„å Àℙ⇪ìπ‡Õ° “√Õ“â ßÕ‘ß„¥Ê „π∑“ß°ÆÀ¡“¬

 ∂“∫—π¡–‡√Áß·Ààß™“µ‘¡’Àπâ“∑Ë’√—∫º‘¥™Õ∫°“√ªÑÕß°—π·≈–§«∫§ÿ¡‚√§¡–‡√ÁߢÕߪ√–‡∑»
·≈–‡ªìπ°√√¡°“√/ºŸâ™à«¬‡≈¢“πÿ°“√·≈–§≥–°√√¡°“√ªÑÕß°—π·≈–§«∫§ÿ¡‚√§¡–‡√Áß·Ààß™“µ‘ ®÷ß∑”
Àπâ“∑’ˇªìπ·°π°≈“ß„π°“√®—¥∑”·π«∑“ß°“√µ√«®«‘π‘®©—¬·≈–√—°…“‚√§¡–‡√Áßµ—∫ ·≈–¡–‡√Áß∑àÕπ”È ¥’
‰¥â¥”‡π‘π°“√«“ß·ºπ°“√®—¥∑”·π«∑“ß°“√µ√«®«‘π‘®©—¬ ·≈–√—°…“‚√§¡–‡√Áßµ—∫ ·≈–¡–‡√Áß∑àÕπÈ”¥’
‚¥¬‡™‘≠ª√–∏“π®“°√“™«‘∑¬“≈—¬√—ß ’·æ∑¬å √“™«‘∑¬“≈—¬æ¬“∏‘·æ∑¬å ¡–‡√Áß«‘∑¬“ ¡“§¡·Ààß
ª√–‡∑»‰∑¬ ™¡√¡»≈— ¬·æ∑¬å¡–‡√ßÁ (ª√–‡∑»‰∑¬)  ¡“§¡√ß—  ’√—°…“·≈–¡–‡√ßÁ «‘∑¬“·Àßà ª√–‡∑»‰∑¬
·≈– ¡“§¡·æ∑¬å√–∫∫∑“߇¥π‘ Õ“À“√·Ààߪ√–‡∑»‰∑¬ √à«¡‡ªπì §≥–∑”ß“π ·≈–‡π◊ËÕß®“°Õߧ§å «“¡√Ÿâ
·≈–‡∑§‚π‚≈¬∑’ “ß°“√·æ∑¬å ¡’°“√æ—≤π“ª√—∫‡ª≈’¬Ë πÕ¬à“ß√«¥‡√«Á §≥–º®âŸ ¥— ∑” ¡§’ «“¡‡ÀÁπ«“à §«√¡’
°“√∑∫∑«π ª√∫— ª√ÿß„À∑â —π ¡—¬‡ªπì √–¬–Ê

¢Õ¢Õ∫§ÿ≥∑ÿ°∑à“π∑Ë’¡’ à«π√à«¡„π°“√®—¥∑”Àπ—ß ◊Õ·π«∑“߇≈à¡π’È ·≈–§≥–∑”ß“π¬‘π¥’√—∫§”
«‘®“√≥åµà“ßÊ ∑’Ë®–™à«¬„ÀâÀπ—ß ◊Õ‰¥â√—∫°“√æ—≤π“·≈–ª√—∫ª√ÿß·°â‰¢ Õ—π®–‡ªìπª√–‚¬™πå„π°“√µ√«®
«π‘ ‘®©¬— ·≈–√°— …“ºŸªâ É«¬¡–‡√Áßµ—∫„πª√–‡∑»‰∑¬µàÕ‰ª

§≥–∑”ß“π
°√°Æ“§¡ 2549

°

™π¥‘ ¢Õߧ”·π–π” ™ ‘π¥¢Õߧ”·π–π”
(Categories of Consensus)

· π«∑“߇«™ªØ‘∫—µ‘ ”À√—∫°“√®—¥∑”§àŸ¡◊Õ·π«∑“ß°“√¥Ÿ·≈ºâŸªÉ«¬‚√§¡–‡√Áßµ—∫ ∑Ë’

§≥–∑”ß“πœ ‰¥®â ¥— ∑”¢πÈ÷ ππÈ— ¬¥÷ ∂Õ◊ æπÈ◊ ∞“π®“°°“√»°÷ …“ «®‘ ¬— ·≈–§«“¡‡ÀπÁ æÕâ ߢÕߧ≥–º‡âŸ ™¬Ë’ «™“≠
‚¥¬™π‘¥¢Õß §”·π–π”ª√–°Õ∫¥«â ¬ 2  «à πª√–°Õ∫∑ Ë’ ”§≠— §Õ◊ √–¥∫— §≥ÿ ¿“æ¢ÕßÀ≈°— ∞“π (strength of
evidence) ·≈–√–¥∫— §«“¡‡ÀπÁ À√◊Õ©π— ∑“¡µ‘ (consensus) ¢Õߧ≥–º‡Ÿâ ™¬Ë’ «™“≠ ¥—ßπÈ’

™π‘¥¢Õߧ”·π–π” §≥ÿ ¿“æ¢ÕßÀ≈—°∞“π √–¥—∫§«“¡‡ÀÁπÀ√◊Õ©—π∑“¡µ‘¢Õߧ≥–ºŸ‡â ™Ë’¬«™“≠
1  Ÿß ∑‘»∑“߇¥’¬«°—π
2A ∑‘»∑“߇¥’¬«°π—
2B µ”Ë °«“à
3 µË”°«“à ‰¡à‰ª„π∑»‘ ∑“߇¥’¬«°π—
‰¡¡à ’ ¡’§«“¡‡ÀÁπ¢¥— ·¬âß¡“°

™π‘¥¢Õߧ”·π–π” 1 : §”·π–π”√–¥—∫π’È ‰¥â®“°À≈—°∞“π§ÿ≥¿“æ Ÿß (‡™àπ®“° randomized
clinical trials À√◊Õ meta-analysis) √à«¡°—∫§≥–ºŸâ‡™’ˬ«™“≠¡’©—π∑“¡µ‘
„π∑‘»∑“߇¥’¬«°—π ‚¥¬ºŸâ‡™’ˬ«™“≠ à«π¡“° π—∫ πÿ𧔷π–π”π’È ·≈–
Õ“®¡º’ ⇟ ™¬Ë’ «™“≠∫“ß∑à“π‰¡àÕÕ°§«“¡‡ÀπÁ

™π¥‘ ¢Õߧ”·π–π” 2A : §”·π–π”√–¥∫— π’È ‰¥®â “°À≈°— ∞“π∑¡Ë’ §’ ≥ÿ ¿“æ ∑µË’ ”Ë °«“à ™π¥‘ ¢Õߧ”·π–π”1
(‡™àπ ®“°°“√»÷°…“ phase II À√◊Õ°“√»÷°…“™π‘¥ Cohort ¢π“¥„À≠à
À√Õ◊ ª√– ∫°“√≥åºâŸ‡™¬Ë’ «™“≠À√Õ◊ retrospective studies ®“°ª√– ∫°“√≥å
°“√√—°…“ºŸâªÉ«¬®”π«π¡“°¢Õߺ⟇™Ë’¬«™“≠) √à«¡°—∫§≥–ºŸâ‡™’ˬ«™“≠
¡’©π— ∑“¡µ‘„π∑»‘ ∑“߇¥’¬«°—π

1

™π¥‘ ¢Õߧ”·π–π” 2B : §”·π–π”√–¥∫— π‰’È ¥®â “°À≈°— ∞“π∑¡’Ë §’ ≥ÿ ¿“æµ”Ë °«“à 1 À√Õ◊ 2A ·≈–§≥–
ºâŸ‡™Ë¬’ «™“≠¡§’ «“¡‡ÀπÁ ‰¡‰à ª„π∑‘»∑“߇¥’¬«°—π«“à §”·π–π”π’§È «√𔉪„™â
§”·π–π”πÀ’È ≈°— ∞“π‰¡ à “¡“√∂ √ªÿ ‰¥â ‚¥¬·µ≈à – ∂“∫π— Õ“®¡«’ ∏‘ °’ “√√°— …“
·µ°µ“à ß°π— ‰¥â ∂ß÷ ·¡§â «“¡‡ÀπÁ ¢Õߧ≥–º‡Ÿâ ™¬’Ë «™“≠‰¡‰à ª„π∑»‘ ∑“߇¥¬’ «°π—
·µà‰¡à¡’§«“¡‡ÀÁπ∑Ë’¢—¥·¬âß°—π¡“° ¥—ßπ—Èπ™π‘¥§”·π–π” 2B ºâŸª√–°Õ∫
«™‘ “™æ’ ‡«™°√√¡Õ“® “¡“√∂‡≈Õ◊ °«∏‘ ª’ Ø∫‘ µ— ‰‘ ¥¡â “°°«“à 1 «∏‘ ¢’ π÷È °∫— À≈°— ∞“π
∑“ߧ≈π‘ ‘°∑’¡Ë ’

™π‘¥¢Õߧ”·π–π” 3 : §”·π–π”√–¥—∫πÈ’§≥–ºâŸ‡™’ˬ«™“≠¡’§«“¡‡ÀÁπ¢—¥·¬âß°—π¡“°´÷Ëߧ”·π–π”
√–¥∫— 3 π’È µÕâ ß¡º’ ‡âŸ ™¬Ë’ «™“≠¡“°°«“à À√Õ◊ ‡∑“à °∫— 2 §π ‡ÀπÁ æÕâ ß„π§”·π–π”
§«“¡¢—¥·¬âß„π§«“¡‡ÀÁπ À√◊Õ§”·π–π”π’ÈÕ“®‡°‘¥®“°À≈—°∞“π∑Ë’‰¥âπÈ—π
¬—߉¡à‰¥â¡’°“√‡ª√’¬∫‡∑’¬∫‚¥¬ randomized trial ¥—ßπÈ—π™π‘¥§”·π–π”
√–¥—∫ 3 ºâŸª√–°Õ∫«‘™“™’懫™°√√¡§«√æ‘®“√≥“¢âÕ¡Ÿ≈„π∫∑§«“¡ ´Ë÷ß®–
°≈“à «∂ß÷ §«“¡§‘¥‡ÀπÁ ∑’Ë·µ°µ“à ß°π—

À¡“¬‡Àµÿ ‚¥¬§”·π–π”®–‡ªπì ™π‘¥¢Õߧ”·π–π” 2A ¬°‡«âπ®–√–∫ÿ‰«‡â ªìπ™π¥‘ Õ◊Ëπ

2

¡–‡√Áßµ∫— Hepatocellular Carcinoma Hepatocellular Carcinoma

✦ ·ºπ¿¡Ÿ ‘· ¥ß¢—ÈπµÕπ°“√¥·Ÿ ≈√—°…“¡–‡√Áßµ∫—
✦ ·π«∑“ß°“√µ√«®§¥— °√Õß «π‘ ®‘ ©¬— ·≈–√°— …“¡–‡√ßÁ µ∫—
✦ ·π«∑“ß°“√√—°…“¡–‡√ßÁ µ—∫·≈–°“√µ√«®µ¥‘ µ“¡
✦ ·π«∑“ß°“√„™√â —ß ’√°— …“„π¡–‡√ßÁ µ∫—
✦ ·π«∑“ß°“√®—¥√–¬–‚√§¡–‡√Áßµ∫—

3

·ºπ¿¡Ÿ ·‘  ¥ß

¢È—πµÕπ°“√¥·Ÿ ≈√—°…“¡–‡√Áßµ∫—

™¡√¡»—≈¬·æ∑¬å¡–‡√ßÁ (ª√–‡∑»‰∑¬)
™¡√¡»—≈¬·æ∑¬åµ∫— µ∫— ÕàÕπ ·≈–∑“߇¥‘ππÈ”¥’

4

Management of No Surgical Yes Hepatic
Hepatocellular Carcinoma Candidate resection

Scale Major No Distant OLT
0-2
vascular metastasis No Tumor
ablation
invasion**
TACE
Child- Performance Yes Yes
Pugh A Status Supportive care
or B* or

Liver mass Scale Clinical trial
suspicious 3-4
for HCC Supportive
care
Child- Tumor : single >5 cm or >3 lesions (each >3 cm) or Yes
Pugh C Vascular invasion or metastasis or No OLT
Performance status scale 3-4 Tumor
ablation

* Consider in patient with portal hypertension and thrombocytopenia
**Main portal vein and/or IVC involvement-detected by 2 imaging studies (ultrasonography, CT, MRI)

TACE : Transarterial chemoembolization, OLT: Orthotopic liver transplantation, RF: Radiofrequency

5

Hepatocellular Carcinoma

6

Rupture of Hepatocellular Carcinoma

Presentation Work up Treatment

● Sudden epigastric or ● Abdominal paracentesis Immediate management
right hypochondriac - Blood-stained ascites ● Hemodynamic resuscitation
pain - Unclotted blood ● Consider blood replacement,

● Signs of peritonitis with ● Ultrasonography : hyperechoic correction of coagulopathy
abdominal distension area around tumor ● Cardiovascular monitoring

● Hypovolemic Shock ● CT scan*
● Angiography

* Suggestive signs of rupture of hepatocellular carcinoma: Hypervascular mass, Mass closed to liver
capsule, Protusion mass, Subtle rim enhancement (enucleation sign), Densely enhancing peripheral rim
with marginal break, Extravasation of contrast media, Free fluid intraperitoneum

Rupture of Hepatocellular Carcinoma

Unstable Conservative treatment if Unstable
hemodynamic ● Moribund patient hemodynamic
● Malignant cachexia
Immediate ● Terminal liver failure
management ● Extrahepatic metastasis
● Terminal event

Emergency surgery
● Packing
● Absolute ethanol injection or

tumor ablation
● Resection or debridement of

rupture tumor
● Hepatic artery ligation (optional)

Transarterial embolization
(TAE)/TACE

Stable Assessment Consider elective
hemodynamic (US, CT, MRI) surgery

7

Hepatocellular Carcinoma

·π«∑“ß°“√µ√«®§¥— °√Õß«π‘ ®‘ ©—¬
·≈–√°— …“ºªâŸ «É ¬¡–‡√Áßµ∫—

 ¡“§¡·æ∑¬√å –∫∫∑“߇¥‘πÕ“À“√·Ààߪ√–‡∑»‰∑¬

§≥–º®Ÿâ ¥— ∑”

1. »“ µ√“®“√¬·å æ∑¬Àå ≠‘ß™ÿµ¡‘ “ ª√–¡Ÿ≈ ‘π∑√æ— ¬å
2. »“ µ√“®“√¬·å æ∑¬Àå ≠ß‘ °√√≥°‘ “√å æ√æ—≤πå°ÿ≈
3. √Õß»“ µ√“®“√¬πå “¬·æ∑¬æå ‘»“≈ ‰¡‡â √¬’ ß
4. æπ— ‡Õ°π“¬·æ∑¬åÕπÿ™µ‘ ®Ÿ±–æ∑ÿ ∏‘
5. º™âŸ «à ¬»“ µ√“®“√¬å𓬷æ∑¬∑å «’»—°¥Ï‘ ·∑π«—π¥’
6. √Õß»“ µ√“®“√¬πå “¬·æ∑¬∏å ’√– æ√‘ —™«‘ ÿ∑∏Ï‘

8

·π«∑“ß°“√µ√«®«‘π®‘ ©—¬·≈–√°— …“ Hepatocellular Carcinoma

ºªŸâ É«¬¡–‡√Áßµ—∫¢Õߪ√–‡∑»‰∑¬

»“ µ√“®“√¬·å æ∑¬åÀ≠‘ß™ÿµ‘¡“ ª√–¡≈Ÿ  ‘π∑√—æ¬å

¡–‡√Áßµ—∫ (Hepatocellular carcinoma À√◊Õ HCC) ‡ªìπ‚√§∑Ë¡’ ’§«“¡ ”§≠— ∑æË’ ∫‰¥∫â Õà ¬

„πª√–™“°√∑Ë—«‚≈° ®“°¢âÕ¡Ÿ≈¢ÕßÕߧ尓√Õπ“¡—¬‚≈° (WHO) √“¬ß“π«à“æ∫¡“°‡ªìπÕ—π¥—∫ 5
§‘¥‡ªìπ√âÕ¬≈– 5.6 ¢Õß¡–‡√Áß∑È—ßÀ¡¥ ‚¥¬æ∫„π‡æ»™“¬¡“°°«à“À≠‘ß 2-4 ‡∑à“ „πªïæ.». 2543
æ∫Õ∫ÿ µ— °‘ “√≥¢å ÕߺªŸâ «É ¬¡–‡√ßÁ µ∫— „À¡∑à «—Ë ‚≈°ª√–¡“≥ 564,000 §πµÕà ª(ï 1) ºªâŸ «É ¬ «à π„À≠ªà √–¡“≥
271,500 §πÕ¬Ÿà„π∑«’ª‡Õ‡™’¬ (®“°ª√–‡∑»®’π 221,000 §π·≈–≠’˪ÿÉπ 33,000 §π)  ”À√—∫
„π À√—∞Õ‡¡√‘°“·≈–ª√–‡∑»„π∑«’ª¬ÿ‚√ªæ∫ª√–¡“≥ 11,500 §π·≈– 50,000 §πµ“¡≈”¥—∫
·≈–¡’ºŸâ‡ ’¬™’«‘µ®“°¡–‡√Áßµ—∫∑—Ë«‚≈° Ÿß∂÷ß 549,000 §π ®“°√“¬ß“π¢Õß°√–∑√«ß “∏“√≥ ÿ¢
¢Õߪ√–‡∑»‰∑¬ªïæ.».2542 æ∫«à“‚√§¡–‡√Áßµ—∫‡ªì𠓇Àµÿ¢Õß°“√‡ ’¬™’«‘µ·≈–‡®Á∫ªÉ«¬‡√È◊Õ√—ß
®“° “‡Àµ°ÿ “√µ“¬°àÕπ«—¬Õπ— §«√‡ªìπÕπ— ¥—∫ 4 ·≈–‡ªìπ¡–‡√ßÁ ∑’Ëæ∫∫àÕ¬Õπ— ¥—∫ 1 „πºâ™Ÿ “¬·≈–Õπ— ¥—∫ 3
„πºÀ⟠≠‘ß√Õß®“°¡–‡√ßÁ ‡µâ“π¡·≈–¡–‡√Áߪ“°¡¥≈°Ÿ (2)

ªí®®—¬‡ Ë’¬ß ”§—≠µàÕ°“√‡°‘¥¡–‡√Áßµ—∫‰¥â·°à‚√§µ—∫·¢Áß®“°∑ÿ°Ê  “‡Àµÿ ®“°°“√¥Ë◊¡ ÿ√“
·≈–∑’ˇªìπªí≠À“ ”§—≠∑—Ë«‚≈°§◊Õ®“°‰«√— µ—∫Õ—°‡ ∫∑È—ß™π‘¥∫’·≈–´(’ 3) ®“°°“√ ”√«®æ∫«à“ª√–‡∑»
‰∑¬¡ª’ √–™“°√¥¡Ë◊  √ÿ “À√Õ◊ ‡§√Õ◊Ë ß¥¡Ë◊ ∑¡’Ë ·’ Õ≈°ÕŒÕ≈¡å “°‡ªπì Õπ— ¥∫— 5 ¢Õß‚≈°(4) πÕ°®“°πªÈ’ ≠í À“‰«√ —
µ—∫Õ—°‡ ∫∫’‡ªìπªí≠À“ ”§—≠ æ∫«à“¡’§π‰∑¬‡ªìπæ“À–π”‚√§π’È°«à“ 6 ≈â“π§π ·≈–¡“°°«à“§√Ë÷ß
¢Õ߇¥Á°·√°‡°‘¥∑Ë’µ‘¥‡™È◊Õ®“°·¡à ´Ë÷ß®–°≈“¬‡ªìπæ“À–À√◊Õµ—∫Õ—°‡ ∫‡√◊ÈÕ√—ß À≈“¬√“¬®–‡ ’¬™’«‘µ¥â«¬
‚√§µ∫— ·¢ÁßÀ√Õ◊ ¡–‡√ßÁ µ∫— °àÕπÕ“¬ÿ 50 ªï (5)

∂÷ß·¡â«à“„πªí®®ÿ∫—π·π«∑“ß°“√«‘π‘®©—¬·≈–«‘∏’°“√√—°…“¡–‡√Áßµ—∫®–°â“«ÀπⓉª¡“°
·µàÕ—µ√“°“√‡ ’¬™’«‘µ¢Õߺ⟪ɫ¬¬—ß Ÿß ·≈– à«π„À≠à‰¥â√—∫°“√«‘π‘®©—¬§√—Èß·√°¡—°Õ¬Ÿà„π√–¬–∑⓬
¢Õß‚√§ ¥—ßπÈ—π∑“ß ∂“∫—π¡–‡√Áß·Ààß™“µ‘√«à ¡°∫— ºâ∑Ÿ √ߧ≥ÿ «ÿ≤‘·≈–·æ∑¬åºâ‡Ÿ ™¬Ë’ «™“≠„π “¢“µà“ßÊ ¢Õß
ª√–‡∑»‰∑¬ ‰¥â·°à ·æ∑¬åºŸâ‡™’ˬ«™“≠∑“ß‚√§µ—∫ ·≈– ¡“§¡‚√§∑“߇¥‘πÕ“À“√·Ààߪ√–‡∑»‰∑¬
·æ∑¬åºŸâ‡™Ë’¬«™“≠∑“ß¡–‡√Áß·≈–‡§¡’∫”∫—¥ »—≈¬·æ∑¬å·≈–√—ß ’·æ∑¬å ‰¥â√–¥¡§«“¡√Ÿâ §«“¡§‘¥‡ÀÁπ
·≈– √ÿª‡ªìπ ç·π«∑“ß„π°“√«‘π‘®©—¬·≈–√—°…“ºâŸªÉ«¬¡–‡√Áßµ—∫¢Õߪ√–‡∑»‰∑¬é ‚¥¬Õ“»—¬
·π«∑“ß„π°“√«‘π‘®©—¬ ·≈–√—°…“ºŸâªÉ«¬¡–‡√Áßµ—∫®“°µà“ߪ√–‡∑» ‡æË◊Õ„Àâ‡À¡“– ¡·≈–
‡ªìπ·π«∑“ß„π°“√«‘π‘®©¬— ·≈–√—°…“ºâŸªÉ«¬¡–‡√Áßµ∫— ¢Õߪ√–‡∑»‰∑¬

9

À≈—°°“√·≈–‡Àµºÿ ≈„π°“√µ√«®§—¥°√Õß·≈–°“√‡Ω“Ñ √–«—ß‚√§¡–‡√Áßµ∫—
(Screening and surveillance)

Õߧ尓√Õπ“¡—¬‚≈° (World Health Organisation; WHO) ‰¥°â ”Àπ¥À≈°— ‡°≥±„å π°“√
∑”·π«∑“ß„π°“√µ√«®§—¥°√Õß·≈–°“√‡ΩÑ“√–«ß— ‚√§ ‚¥¬‚√§¥ß— °≈à“«µâÕß¡‡’ ßÕË◊ π‰¢∑ ’Ë ”§≠— ¥—ßπ(’È 7)

1. ‡ªìπªí≠À“∑“ß “∏“√≥ ¢ÿ  ”§—≠¢Õߪ√–™“°√
2.  “¡“√∂∫Õ°°≈¡ÿà ‡ ¬’Ë ß‰¥â
3. °“√¥”‡ππ‘ ‚√§„™‡â «≈“æÕ§«√ ´÷Ëß “¡“√∂µ√«®§¥— °√Õ߉¥°â Õà π∑Ë’®–¡’Õ“°“√∑“ߧ≈‘π‘°
4. «∏‘ °’ “√µ√«®µâÕߧÿ⡧“à ª≈Õ¥¿—¬ §à“„™â®“à ¬‰¡ à Ÿß·≈–‡ªìπ∑ˬ’ Õ¡√∫—
5. ∂“â «‘π‘®©—¬‰¥µâ È—ß·µ√à –¬–‡√‘Ë¡µâπ  “¡“√∂√—°…“À“¬¢“¥·≈–‡æ‘¡Ë Õ—µ√“√Õ¥™«’ µ‘
‚√§¡–‡√Áßµ—∫‡¢â“‡°≥±å¥—ß°≈à“«∂÷ß 4 ¢âÕ·√° ¥—ßπ—Èπ®÷߇ªìπ∑’ˬա√—∫∑—Ë«‚≈°„π°“√∑”
·π«∑“ß„π°“√µ√«®§—¥°√Õß·≈–°“√‡ΩÑ“√–«—ß‚√§¡–‡√Áßµ∫— ∂ß÷ ·¡â‡°≥±¢å Õâ 5 ¬—߉¡ à √ÿª™¥— ‡®π

°≈ÿ¡à ‡ Ë’¬ßµàÕ°“√‡°¥‘ ¡–‡√ßÁ µ∫—

Recommendation 1 °≈à¡ÿ ‡ Ë¬’ ß∑§’Ë «√‰¥√â ∫— °“√µ√«®§—¥°√ÕßÀ“‚√§¡–‡√Áßµ—∫(6) ‰¥·â °à
1. ºªâŸ «É ¬‚√§µ∫— ·¢ßÁ ∑ß—È ‡æ»À≠ß‘ ·≈–™“¬ (™π‘¥¢Õߧ”·π–π”2A) ªí®®—¬‡ ’ˬߵàÕ°“√‡°‘¥
¡–‡√ßÁ µ∫— ¡À’ ≈“¬Õ¬“à ß ‰¥·â °à ‚√§µ∫— ·¢ßÁ ®“°∑°ÿ  “‡Àµÿ  √ÿ “ ‰«√ — µ∫— Õ°— ‡ ∫∫·’ ≈–´’  “√æ…‘ Õ–ø≈“∑Õä °´π‘
¿“«–∏“µ‡ÿ À≈Á° – ¡∑’˵∫— ‚√§∑“ßæ—π∏ÿ°√√¡·≈–‡¡µ“∫Õ≈°‘ µà“ßÊ œ≈œ æ∫«“à √Õâ ¬≈– 80 ¢Õß¡–‡√Áß
µ—∫‡°‘¥„πºâŸªÉ«¬∑Ë’‡ªìπ‚√§µ—∫·¢Áß „π¢≥–∑Ë’Õÿ∫—µ‘°“√≥å°“√‡°‘¥¡–‡√Áßµ—∫®“°‚√§µ—∫ÕË◊πÊ ∑Ë’¬—߉¡à‡ªìπ
µ∫— ·¢ßÁ æ∫«“à Õ∫ÿ —µ°‘ “√≥剡à ßŸ ¡“°π°—
2. ºâªŸ «É ¬‚√§µ∫— Õ°— ‡ ∫‡√Õ◊È √—ß∑Ë’‡°‘¥®“°‰«√ — µ—∫Õ°— ‡ ∫∫’ À√Õ◊ ºâŸ∑’˵‘¥‡™◊ÕÈ ‰«√ — µ∫— Õ°— ‡ ∫∫’
µßÈ— ·µ·à √°§≈Õ¥À√Õ◊ «¬— ‡¥°Á ·≈–¬ß— ‰¡¡à ‚’ √§µ∫— ·¢ßÁ ·µ¡à §’ «“¡‡ ¬’Ë ßµÕà ¡–‡√ßÁ µ∫—  ßŸ „π‡æ»™“¬Õ“¬¡ÿ “°°«“à
45 ªï ·≈–ºâŸÀ≠‘ßÕ“¬¡ÿ “°°«“à 50 ªï ·≈–¡ª’ √–«µ— ¡‘ –‡√ßÁ µ∫— „π§√Õ∫§√—«
3. ºâŸªÉ«¬‚√§‰«√— µ—∫Õ—°‡ ∫´’‡√È◊Õ√—ß∑’Ë¡’ fibrosis stage 3 ·≈– 4 §«√‰¥â√—∫°“√
µ√«®§¥— °√Õß‚√§¡–‡√ßÁ µ—∫

«∏‘ ’°“√·≈–√–¬–‡«≈“°“√µ√«®§¥— °√Õß¡–‡√Áßµ—∫

Recommendation 2 «∏‘ °’ “√µ√«®§—¥°√ÕßÀ“‚√§¡–‡√ßÁ µ∫— §«√∑”„πª√–™“°√°≈à¡ÿ ∑Ë’¡’
§«“¡‡ ’ˬߵàÕ¡–‡√Áßµ∫— ‚¥¬µ√«®‡≈Õ◊ ¥À“§à“ Alfa-fetoprotein (AFP) √à«¡°∫— °“√∑” ultrasonography
(US) ∑°ÿ 6 ‡¥Õ◊ π(6,8) (™π¥‘ ¢Õߧ”·π–π” 2A)

ªí®®ÿ∫—π°“√µ√«®«‘π‘®©—¬‚√§¡–‡√Áßµ—∫¡’§«“¡°â“«Àπâ“¡“° ‚¥¬∑Ë—«‰ªÕ“»—¬°“√µ√«®
tumor markers √«à ¡°∫— °“√µ√«®∑“ß√—ß ’·≈–/À√Õ◊ °“√µ√«®™π‘È ‡πÕ◊È µ∫— tumor markers ∑’Ë ”§—≠‰¥â·°à

10

Alfa-fetoprotein (AFP) ¡’§à“ª°µ‘ 10-20 ng/ml ·≈–§à“∑Ë’„™â«‘π‘®©—¬¡–‡√Áßµ—∫∂â“¡“°°«à“ Hepatocellular Carcinoma
400 ng/ml  à«π tumor markers ÕË◊πÊ∑Ë’Õ¬àŸ„π√–À«à“ß°“√»÷°…“·≈–¡’·π«‚πâ¡Õ“®®–™à«¬«‘π‘®©—¬
¡–‡√ßÁ µ∫— ‰¥·â °à des-gamma carboxyprothrombin, lens culinaris agglutinin-reactive AFP, human
hepatocyte growth factor ·≈– insulin-like growth factor-1 ‡ªπì µπâ

°“√µ√«®∑“ß√ß—  ¡’ À’ ≈“¬«∏‘ ’ ‰¥·â °à °“√∑” ultrasonography (US), computer tomography
(CT), magnetic resonance imaging (MRI), angiography ·≈– positron emission tomography
(PET scan) œ≈œ

«∏‘ ∑’ ¬Ë’ Õ¡√∫— ·≈–‡≈Õ◊ °„™„â π°“√µ√«®§¥— °√ÕßÀ“¡–‡√ßÁ µ∫— ∑«—Ë ‚≈°„πª®í ®∫ÿ π— ‰¥·â °°à “√µ√«®
AFP √«à ¡°—∫ US ∑ÿ° 3-6 ‡¥Õ◊ π „πª√–™“°√°≈ÿࡇ ¬Ë’ ßµàÕ°“√‡°‘¥¡–‡√ßÁ µ—∫

·π«∑“ß°“√µ√«®§—¥°√Õß·≈–«‘π‘®©¬— ‚√§¡–‡√Áßµ—∫

Recommendation 3 ·π«∑“ß°“√µ√«®§—¥°√Õß·≈–«‘π‘®©—¬‚√§¡–‡√Áßµ—∫„π°≈ÿࡇ Ë’¬ß Ÿß
‡¡◊ËÕµ√«®§—¥°√Õß¡–‡√Áßµ—∫„π°≈àÿ¡‡ Ë’¬ß‚¥¬°“√∑” US √à«¡°—∫ AFP ∂â“≈—°…≥–°âÕπ¡’ arterial
hypervascularization ·≈–¢π“¥¡“°°«à“ 2 ‡´πµ‘‡¡µ√ ®“° 2 «‘∏’ ‰¥â·°à US, CT ·≈–/À√◊Õ MRI
·≈–¡’ AFP ¡“°°«à“ 400 ng/ml  “¡“√∂„Àâ°“√«‘π®‘ ©—¬‡ªìπ¡–‡√ßÁ µ∫— (Diagnosis of HCC) ‚¥¬‰¡µà âÕß
µ√«®™π‘È ‡πÕ◊È µ—∫ ·≈–πÕ°®“°°√≥¥’ ß— °≈à“«µ√«® US ·≈– AFP „Àªâ Ø‘∫—µ‘¥—ßπ’È (9,10)
1.°√≥’µ√«®æ∫°Õâ π‚¥¬ US „Àæâ ®‘ “√≥“§“à AFP ¥—ßπ’È

1.1 US æ∫°âÕπ¢π“¥πÕâ ¬°«“à 2 ‡´πµ‘‡¡µ√ ·≈–§à“ AFP ª°µ‘
1.1.1. „Àµâ √«®µ¥‘ µ“¡º≈ US ·≈– AFP ∑°ÿ 3 ‡¥Õ◊ π À√◊Õ
1.1.2. Õ“®æ®‘ “√≥“∑” CT À√◊Õ MRI „π∫“ß√“¬ ·≈–æ‘®“√≥“µ“¡¢âÕ 1.2.1-1.2.3

1.2 US æ∫°Õâ π¢π“¥¡“°°«“à À√◊Õ‡∑“à °∫— 2 ‡´πµ‡‘ ¡µ√ ·≈–§“à AFP ª°µ‘ „À∑â ” CT À√Õ◊ MRI
·≈«â æ‘®“√≥“≈°— …≥–¢Õß°Õâ π¥—ßπÈ’

1.2.1 ∂“â ≈°— …≥–¢Õß°Õâ π¡’ arterial hypervascularization À√Õ◊ ≈°— …≥–∑‡Ë’ ¢“â ‰¥°â ∫— HCC ¡“° „Àâ
∑”°“√√—°…“‚¥¬«‘∏’º“à µ—¥ À√Õ◊ °“√∑”≈“¬°âÕπ¥â«¬·Õ≈°ÕŒÕ≈≈å À√◊Õ§«“¡√âÕπ

1.2.2 ∂“â ≈°— …≥–¢Õß°Õâ π· ¥ß≈°— …≥–°È”°ßË÷ HCC „Àµâ √«®µ¥‘ µ“¡º≈ US ·≈– AFP ∑°ÿ 3 ‡¥Õ◊ π
À√◊Õ殑 “√≥“µ√«®™È‘π‡πÕ◊È (percutaneous biopsy)

1.2.3 ∂â“≈—°…≥–¢Õß°âÕπ‰¡à‡¢â“°—∫≈—°…≥–¢Õß HCC „Àâµ√«®µ‘¥µ“¡º≈ US ·≈– AFP
∑°ÿ 3 ‡¥◊Õπ

1.3 US æ∫°âÕπ ·≈–§à“ AFP  Ÿß°«à“§à“ª°µ‘ (>200 ng/ml) À√◊Õ§à“ AFP ‡æË‘¡ ŸßÕ¬à“ß™—¥‡®π
„π√–À«“à ß°“√µ√«®µ¥‘ µ“¡º≈ „Àâ∑” CT À√◊Õ MRI ·≈â«æ‘®“√≥“¥—ߢâÕ 1‹ .2.1-1.2.3

2. °√≥µ’ √«® US ‰¡àæ∫°âÕπ „Àâæ‘®“√≥“§“à AFP ¥ß— πÈ’
2.1 §“à AFP ª°µ‘ „Àµâ √««®µ¥‘ µ“¡º≈ US ·≈– AFP ∑°ÿ 6 ‡¥◊Õπ

11

2.2 §“à AFP  Ÿß°«à“§“à ª°µ‘ (>200 ng/ml) À√◊Õ§à“ AFP ‡æ¡‘Ë  ŸßÕ¬“à ß™¥— ‡®π„π√–À«“à ß°“√µ√«®
µ¥‘ µ“¡º≈ „À∑â ” CT À√Õ◊ MRI
2.2.1 ∂“â ‰¡æà ∫§«“¡º‘¥ª°µ„‘ Àµâ √«®µ‘¥µ“¡º≈ US ·≈– AFP ∑°ÿ 6 ‡¥Õ◊ π
2.2.2 ∂“â µ√«®æ∫°Õâ π„Àæâ ®‘ “√≥“µ“¡¢âÕ 1.2.1-1.2.3

°“√√°— …“ºŸªâ «É ¬¡–‡√Áßµ—∫

Recommendation 4 °“√√—°…“ºŸâª«É ¬¡–‡√ßÁ µ∫—

Recommendation 4.1 °àÕπ∑Ë’®–µ—¥ ‘π„®„Àâ°“√√—°…“§«√ª√–‡¡‘π ¿“«–§«“¡√ÿπ·√ß
¢Õß‚√§µ∫— ¢π“¥·≈–√–¬–¢Õß‚√§¡–‡√Áßµ∫—  ¿“æ¢ÕߺªŸâ «É ¬ ·≈– cost-effectiveness

●  ¿“«–§«“¡√ÿπ·√ߢÕß‚√§µ—∫ «à“¡’¿“«–‚√§µ—∫·¢ÁßÀ√◊Õ‰¡à ·≈–∂â“¡’‚√§µ—∫·¢ÁßÕ¬Ÿà
„π√–¬–„¥ (Childûs classification A-C) (¿“§ºπ«° µ“√“ß∑’Ë 1)

●  ¿“æ¢Õߺ⟪ɫ¬ ‰¥â·°à Karnofsky index (¿“§ºπ«° µ“√“ß∑’Ë 2) À√◊Õ ECOG
performance status (¿“§ºπ«° µ“√“ß∑Ë’ 3) ·≈–‚√§ª√–®”µ—«ÕËπ◊ Ê

● ¢π“¥·≈–√–¬–¢Õß‚√§¡–‡√Áßµ—∫ ªí®®ÿ∫—π¡’‡°≥±å«‘π‘®©—¬√–¬–§«“¡√ÿπ·√ߢÕß
¡–‡√ßÁ µ∫— À≈“¬Õ¬“à ß∑π’Ë ¬‘ ¡„™·â æ√Àà ≈“¬(11-12) ‰¥·â °à Okuda classification, Barcelona
Clinic Liver Cancer (BCLC) Group classification, French classification,
TNM classification, Chinese University Prognostic Index (CUPI) classification
·≈–∑’Ë„™â„πÀ≈“¬ª√–‡∑»√«¡∂÷ߪ√–‡∑»‰∑¬‡π◊ËÕß®“°∫հ欓°“√≥å¢Õß‚√§‰¥â¥’§◊Õ
Cancer of the Liver Italian Program (CLIP) classification

Recommendation 4.2 «‘∏’°“√√—°…“(6,9-10)
1. Curative treatments ‰¥·â °à °“√º“à µ¥— ‡Õ“°Õâ πÕÕ° (resection) (™π¥‘ ¢Õߧ”·π–π” 1 )
·≈–°“√ºà“µ—¥‡ª≈Ë’¬πµ—∫ (liver transplantation)(6,9-10,13) ‚¥¬æ‘®“√≥“∑”∂â“¡’°âÕπ‡¥’¬«·≈–
¡’¢π“¥‡≈°Á °«à“ 5 ‡´πµ‡‘ ¡µ√ À√◊Õ¡’πâÕ¬°«à“ 3 °âÕπ·≈–·µà≈–°âÕπ¡¢’ 𓥉¡‡à °π‘ 3 ‡´πµ‡‘ ¡µ√  «à π
°“√º“à µ¥— ‡Õ“°Õâ πÕÕ°„À∑â ”„πºªâŸ «É ¬∑¬Ë’ ß— ‰¡‡à ªπì µ∫— ·¢ßÁ À√Õ◊ ‡ªπì ‚√§µ∫— ·¢ßÁ √–¬–·√° (Child-Pugh A)
·≈–°âÕπ¡’¢π“¥‡≈Á°¥ß— °≈“à «
2. Percutaneous treatments(6,9-10,14) ‡ªìπ°“√√—°…“¡–‡√Áßµ—∫√–¬–‡√‘Ë¡µâπ„π√“¬∑Ë’‰¡à
 “¡“√∂ºà“µ¥— ‰¥â ‰¥·â °à percutaneous ethanol injection (PEI) À√◊Õ acetic acid, thermal ablation
¥«â ¬ liquid nitrogen (cryoablation), microwaves, laser, ·≈– radiofrequency (RF) ‡ªπì µπâ

● Percutaneous ethanol injection (PEI)(14) ‡À¡“– ”À√—∫ peripheral lesions
∑’Ë¡’¢π“¥πÕâ ¬°«à“ 3 ‡´πµ‘‡¡µ√

● Radiofrequency ablation(14-15) ‡ªìπ°“√√—°…“‚¥¬„™â§≈◊Ëπ™—°π”„À⇰‘¥°√–· 
‰øøÑ“ ≈—∫¢È÷π¿“¬„π‡´≈≈å ·≈⫇ª≈’ˬπ‡ªìπæ≈—ßß“π§«“¡√âÕπ∑”≈“¬‡´≈≈å¡–‡√Áß ¡–‡√Áß∑Ë’√—°…“¥â«¬«‘∏’
π§’È «√¡’¢π“¥‡≈°Á °«à“ 3 ‡´πµ‡‘ ¡µ√

12

3. Palliative treatments „π√“¬∑Ë’‰¡à “¡“√∂√—°…“‚¥¬«‘∏’¢â“ßµâπ‰¥â ·≈–¡–‡√ÁßÕ¬àŸ„π Hepatocellular Carcinoma
√–¬–ª“π°≈“ß∂ß÷ ¡“° ‰¥â·°à embolization/chemoembolization, tamoxifen, arterial À√◊Õ systemic
chemotherapy, internal radiation ¥â«¬ “√ iodine-131, immunotherapy, interferon œ≈œ

● Chemoembolization(14,16-19) º≈°“√√—°…“æ∫«à“∂⓵—∫ à«π∑Ë’‡À≈◊Õ¬—ß∑”ß“π¥’
«‘∏’πÈ’ “¡“√∂‡æ‘Ë¡Õµ— √“°“√√Õ¥™’«‘µ‰¥â

● Systemic chemotherapy(22-23) º≈°“√√°— …“¬ß— ‰¥ºâ ≈‰¡¥à π’ °— ·π–π”„À„â ™„â π°√≥’
clinical trial

● Tamoxifen‰¡‡à æ¡‘Ë Õµ— √“°“√√Õ¥™«’ µ‘
● Long acting octreotide ¢Õâ ¡Ÿ≈‰¡à¡“°æÕ«“à ‰¥âº≈¥’

·π«∑“ß„π°“√√°— …“ºªŸâ É«¬¡–‡√Áßµ—∫

Recommendation 5 ·π«∑“ß„π°“√√°— …“ºŸªâ «É ¬¡–‡√Áßµ—∫ ´÷ßË „À⥄Ÿ πÀπ“â ∑Ë’ 17 πÕ°®“°π’È
¬ß— ¡·’ π«∑“ß°“√√°— …“∑·Ë’ π–π”‚¥¬ European Association for the Study of the Liver ‡ªπì µ«— Õ¬“à ßÀπßË÷
¢Õß·π«∑“ß°“√√°— …“„πª√–‡∑»∑“߬ÿ‚√ª  ”À√∫— ª√–‡∑»‰∑¬¥Ÿ·ºπ¿¡Ÿ ‘Àπâ“ 5

·ºπ¿Ÿ¡‘ 1 ·π«∑“ß„π°“√√°— …“ºŸªâ «É ¬¡–‡√ßÁ µ∫—

HCC

Stage O Stage A-C Stage A-C
ST O, Child-Pugh A, Okuda 1 Okuda 1-2, PST 0-2, Child-Pugh A-B Okuda 3, PST >2, Child-Pugh C

Very early stage (O) Early stage (A) Intermediate stage (B) Advanced stage (C) Terminal stage (D)
1 HCC <2 cm
Carcinoma in situ 1 HCC or 3 nodules Multinodules, Portal invasion,

<3 cm, PST 0 PST 0 N1, M1, PST 1-2

1 HCC 3 nodules <3 cm Portal invasion, N1, M1

Portal pressure/bilirubin Associated
Increased diseases

Normal No Yes No Yes

Resection Liver transplantation* PEI/radiofrequency Chemoembolisation New agents

Curative treatments Randomised controlled triais Symptomatic
treatment

PST = performance status test. N = nodules. M = metastases. PEI = percutaneous ethanol injection.

*Cadaveric liver transplantation or living donor liver transplantation.

13

°“√ªÕÑ ß°—π°“√‡°¥‘ ¡–‡√Áßµ—∫ (Prevention of hepatocellular carcinoma)

Recommendation 6
Recommendation 6.1 Primary prevention ‰¥·â °à °“√ªÕÑ ß°π— ‰¡„à À⇪πì ‚√§µ—∫
✦ ‰¡¥à ¡Ë◊  ÿ√“À√Õ◊ ∂“â ¥Ë◊¡ §«√¥◊¡Ë ª√¡‘ “≥‰¡¡à “° πâÕ¬°«à“ 40-80 °√¡— µÕà «—π ·≈–‰¡¥à ◊¡Ë

µ‘¥µàÕ°—π‡ªπì ‡«≈“π“π
✦ ©’¥«—§´’πªÑÕß°—π‰«√— µ—∫Õ—°‡ ∫∫’ ®“°‰µâÀ«—πæ∫«à“ À≈—ß®“°¡’°“√„Àâ«—§´’π

ªÑÕß°—π‰«√— µ—∫Õ—°‡ ∫∫’ æ∫«à“ “¡“√∂≈¥Õ—µ√“°“√µ‘¥‡™◊ÈÕ ¿“«–µ—∫·¢Áß·≈–
¡–‡√Áßµ—∫‰¥â™—¥‡®π  ”À√—∫ª√–‡∑»‰∑¬‰¥â¡’°“√√≥√ߧå„Àâ©’¥«—§´’πªÑÕß°—π‰«√— 
µ—∫Õ—°‡ ∫∫’„π∑“√°·√°§≈Õ¥ πÕ°®“°π’ȧ«√·π–π”„Àâ©’¥«—§´’πªÑÕß°—π‰«√— 
µ—∫Õ°— ‡ ∫∫’„π°≈¡ÿà ∑’¡Ë ’§«“¡‡ ’ˬߵàÕ°“√µ¥‘ ‡™È◊Õ‡™πà ∫ÿ§§≈“°√∑“ß°“√·æ∑¬å º∑⟠µ’Ë Õâ ß
‰¥â√—∫‡≈◊Õ¥∫àÕ¬Ê ºâªŸ «É ¬∑Ë’øÕ°‰µ ·≈–„πºâªŸ É«¬∑Ë¡’ ’‚√§µ∫— ®“° “‡ÀµÿÕ◊πË Ê
✦ ‰«√— µ—∫Õ—°‡ ∫´’ ‡πË◊Õß®“°¬—߉¡à¡’«—§´’π °“√ªÑÕß°—π∑’Ë¥’∑Ë’ ÿ¥ §◊ÕªÑÕß°—π°“√µ‘¥‡™◊ÈÕ
∑“߇≈Õ◊ ¥ ·≈–‰¡ à ” àÕπ∑“߇æ»
✦ „À⬓µ“â π‰«√ — „πºªŸâ «É ¬‰«√— µ—∫Õ—°‡ ∫‡√ÈÕ◊ √ß— ™π‘¥∫·’ ≈–´’∑¡Ë’ ¢’ âÕ∫àß™’È·≈–‰¡à¡’¢âÕÀ“â ¡
„π°“√√°— …“
✦ À≈’°‡≈Ë’¬ßÕ“À“√∑Ë’ªπ‡ªóôÕπ‡™È◊Õ√“ Aspergillus flavus ·≈– A. parasiticus ´Ë÷ߺ≈‘µ
 “√Õ–ø≈“∑ÁÕ°´‘𠇪πì  “√°Õà ¡–‡√Áß„πµ—∫
✦ °“√µ√«®§—¥°√Õß¿“«–∏“µÿ‡À≈Á° – ¡„πµ—∫ „πµà“ߪ√–‡∑»¡’Õÿ∫—µ‘°“√≥å¢Õß¿“«–
‡À≈°Á  – ¡„πµ∫— (haemochromatosis)  ßŸ ®ß÷ ¡°’ “√·π–π”„Àµâ √«®§¥— °√Õß·≈–√°— …“
¿“«–¥—ß°≈“à « ·µà„πª√–‡∑»‰∑¬Õÿ∫µ— °‘ “√≥å‚√§π‰È’ ¡à¡“° ®÷߉¡‰à ¥¡â ’¢âÕ·π–π”„Àâµ√«®
µ√«®§¥— °√Õß¿“«–¥ß— °≈à“«
Recommendation 6.2 Secondary prevention ‚¥¬°“√¢—¥¢«“ߢ∫«π°“√‡¡µ“∫Õ≈‘´÷¡
¢Õß “√°Õà ¡–‡√ßÁ
Recommendation 6.3 Tertiary prevention ‚¥¬°“√ªÑÕß°π— ‰¡„à Àâ precancerous lesions
‡ª≈Ë’¬π‡ªπì ‡´≈≈å¡–‡√ßÁ

14

References Hepatocellular Carcinoma

1. Bosch FX, Ribes J, Cleries R, Diaz M. Epidemiology of hepatocellular carcinoma. Clin Liver Dis. 2005;
9:191-211.

2. Srivatanakul P. Epidemiology of Liver Cancer in Thailand. Asian Pac J Cancer Prev. 2001; 2:117-121.
3. Sherman M.Hepatocellular carcinoma: epidemiology, risk factors, and screening. Semin Liver Dis.

2005;25:143-54.
4. ·π«§‘¥·≈– ∂“π°“√≥姫“¡¡—Ëπ§ß¢Õß¡πÿ…¬å„π —ߧ¡‰∑¬. °“√»÷°…“·≈–æ—≤π“¡“µ√∞“π·≈–µ—«™È’«—¥

§«“¡¡Ë—π§ß¢Õß¡π…ÿ ¬.å °√–∑√«ß°“√æ—≤π“ ß— §¡·≈–§«“¡¡—πË §ß¢Õß¡πÿ…¬å 2547.
5. Mericam I, Guan R, Amarapuka D, et al. Chronic hepatitis B virus infection in Asian countries. J Gastroenterol

Hepatol. 2000;15:1356-61.
6. Ryder SD. Guidelines for the diagnosis and treatment of hepatocellular carcinoma (HCC) in adults.

Gut.2003;52 (Suppl 3) :iii 1-8.
7. Meissner HI, Smith RA, Rimer BK, et al. Promoting cancer screening: learning from experience. Cancer.

2004;101:1107-7.
8. Sala M, Varela M, Forner A, Bruix J. Early diagnosis of liver cancer. Gastroenterol Hepatol. 2005;28:292-7.
9. Llovet JM. Updated treatment approach to hepatocellular carcinoma. J Gastroenterol. 2005;40:225-35.
10. Bruix J, Sherman M, Llovet JM, et al. Clinical management of hepatocellular carcinoma. Conclusions of the

Barcelona-2000 EASL conference. European Association for the Study of the Liver. J Hepatol.
2001;35:421-30.
11. Sala M, Forner A, Varela M, Bruix J. Prognostic prediction in patients with hepatocellular carcinoma. Semin
Liver Dis. 2005;25:171-80.
12. Marrero JA, Fontana RJ, Barrat A, et al. Prognosis of hepatocellular carcinoma:comparison of 7 staging
systems in an American cohort. Hepatology. 2005;41:707-16.
13. Fuster J, Charco R, Llovet JM, et al. Liver transplantation in hepatocellular carcinoma. Transpl Int.
2005;18:278-82.
14. Llovet JM, Sala M. Non-Surgical therapies of hepatocellular carcinoma. Eur J Gastroenterol Hepatol.
2005;17:505-13.
15. Sala M, Llovet JM, Vilana R, et al. Initial response to percutaneous ablation predicts survival in patients
with hepatocellular carcinoma. Hepatology. 2004; 40:1352-60.
16. Poon RT, Ngan H, Lo CM, et al. Transarterial chemoembolization for inoperable hepatocellular
carcinoma and postresection intrahepatic recurrence. J Surg Oncol. 2000; 73:109-14.
17. Camma C, Schepis F, Orlando A, et al. Transarterial chemoembolization for umresectable hepatocellular
carcinoma: Meta-anadomized controlled trials. Radiology. 2002;224:47-54.
18. Llovet JM, Bruix J. Systematic review of randomized trials for unresectable hepatocellular carcinoma:
Chemoembolization improves survival. Hepatology. 2003; 37:429-42.
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127 (5 Suppl 1) : S179-88.
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carcinoma: A randomized controlled trial. Arch Surg. 1998; 133:183-8.
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resection for hepatocellular carcinoma. Br J Surg. 1996; 83:336-40.
22. Llove JM, Mas X, Aponte JJ, et al. Cost effectiveness of adjuvant therapy for hepatocellular acrcinoma
during the waiting list for liver transplantation. Gut. 2002; 50:123-8.
23. Thomas MB, Zhu AX. Hepatocellular carcinoma: the need for progress. J Clin Oncol. 2005; 23:2892-9.

15

·π«∑“ß„π°“√√—°…“¡–‡√ßÁ µ∫—
·≈–°“√µ√«®µ‘¥µ“¡

™¡√¡»—≈¬·æ∑¬¡å –‡√Áß (ª√–‡∑»‰∑¬)
™¡√¡»—≈¬·æ∑¬åµ∫— µ∫— ÕàÕπ ·≈–∑“߇¥‘ππÈ”¥’

§≥–º®âŸ —¥∑”

1. √Õß»“ µ√“®“√¬å𓬷æ∑¬«å —™√æß»å æÿ∑∏ ‘ « — ¥‘Ï
2. 𓬷æ∑¬∏å √’ «ÿ≤‘ §ŸÀ–‡ª√¡–
3. »“ µ√“®“√¬πå “¬·æ∑¬∏å πæ≈ ‰À¡·æß
4. √Õß»“ µ√“®“√¬å𓬷æ∑¬¥å √‘π∑√å ‚≈àÀå»√‘ ‘«≤— πå
5. ¥√.𓬷æ∑¬å¬ß¬∑ÿ ∏ »‘√‘«≤— πÕ—°…√
6. º™Ÿâ «à ¬»“ µ√“®“√¬πå “¬·æ∑¬å≥√ß§å ¢—πµ’·°â«
7. 𓬷æ∑¬°å «‘≠ ≈≈’ –«≤— πå
8. 𓬷æ∑¬åÕ“§¡ ™¬— «√’ –«—≤π–
9. æπ— ‡Õ°π“¬·æ∑¬å ÿ∑∏®‘µ ≈’≈“ππ∑å
10. 𓬷æ∑¬™å —¬¬“ ®—π∑√å„ 
11. 𓬷æ∑¬‡å æ™√ ‡°…µ√ «ÿ √√≥
12. ºâ™Ÿ «à ¬»“ µ√“®“√¬å𓬷æ∑¬∫å ≠ÿ ™Ÿ »‘√‘®‘𥓰ÿ≈
13. √Õß»“ µ√“®“√¬πå “¬·æ∑¬å √ÿ »—°¥Ï‘ ≈≈’ “Õ¥ÿ ¡≈‘ªî
14. 𓬷æ∑¬å«ÿ≤‘  ÿ‡¡∏‚™µ‡‘ ¡∏“

16

·π«∑“ß„π°“√√—°…“¡–‡√ßÁ µ—∫ Hepatocellular Carcinoma

¥√.𓬷æ∑¬å¬ß¬∑ÿ ∏ »‘√«‘ —≤πÕ°— …√

∫∑π”

Hepatocellular carcinoma (HCC) ‡ªìπ¡–‡√Áߪ∞¡¿Ÿ¡‘∑Ë’æ∫¡“°∑’Ë ÿ¥¢Õßµ—∫ ‡ªìπ¡–‡√Áß
∑Ë’æ∫¡“°Õ—π¥—∫Àâ“ §‘¥‡ªìπ√Õâ ¬≈– 5.6 ¢Õß¡–‡√ßÁ ∑—ÈßÀ¡¥(1) æ∫„π‡æ»™“¬¡“°°«à“‡æ»À≠‘ߪ√–¡“≥
4 ‡∑à“ ¡’ºŸªâ É«¬‡ ’¬™«’ ‘µ®“°¡–‡√ßÁ µ—∫ª∞¡¿Ÿ¡∑‘ Ë«— ‚≈°ª≈ï –‰¡µà ”Ë °«à“Àπ÷Ëß≈â“π§π ·≈–‡ªì𠓇Àµÿ°“√µ“¬
Õ—π¥—∫ “¡„π‡æ»™“¬·≈–Õ—π¥—∫ Ë’„π‡æ»À≠‘ߢÕß “‡Àµÿ°“√µ“¬®“°¡–‡√Áß∑È—ßÀ¡¥ Õÿ∫—µ‘°“√≥å¢Õß
ºâŸªÉ«¬„À¡à∑Ë—«‚≈° Ÿß∂÷ߪ√–¡“≥ 560,000 §πµàÕªï ‚¥¬ª√–¡“≥§√Ë÷ßÀπ÷Ë߇ªìπºŸâªÉ«¬„π∑«’ª‡Õ‡™’¬
µ–«π— ÕÕ°‡©¬’ ß„µ·â ≈–∑«ª’ ·Õø√°‘ “µ–«π— ÕÕ°∑ß—È π‡’È πÕË◊ ß®“°ª®í ®¬— ‡ ¬Ë’ ß∑ ’Ë ”§≠— §Õ◊ ‰«√ — µ∫— Õ°— ‡ ∫∫·’ ≈–´’
°“√¥Ë◊¡ ÿ√“·≈–¿“«–µ—∫·¢Áß „πª√–‡∑»‰∑¬πÈ—π®“° ∂‘µ‘∑’Ë√«∫√«¡‚¥¬ ∂“∫—π¡–‡√Áß·Ààß™“µ‘
æ∫Õÿ∫—µ‘°“√≥å¢Õß‚√§¡–‡√Áßµ—∫ HCC ‡ªìπÕ—π¥—∫Àπ÷Ëß„π‡æ»™“¬ ·≈–Õ—π¥—∫ “¡„π‡æ»À≠‘ß √Õß®“°
¡–‡√Áߪ“°¡¥≈Ÿ°·≈–‡µâ“π¡

„π™à«ß‡«≈“∑Ë’ºà“π¡“ Õ—µ√“°“√µ“¬¢Õߺ⟪ɫ¬ HCC ¬—ß ŸßÕ¬àŸ ¡’°“√欓°√≥å‚√§∑Ë’‰¡à¥’
‡π◊ËÕß®“°¡–‡√Áß™π‘¥π’È¡’≈—°…≥–°“√·∫àßµ—«‡µ‘∫‚µ‡√Á« °“√·æ√à°√–®“¬‡¢â“ Ÿà‡ âπ‡≈◊Õ¥ °“√‡°‘¥
°âÕπ¡–‡√Áß¡“°°«à“ÀπË÷ßµ”·Àπàß·≈–¡—°®–‡°‘¥¡–‡√Áß„πµ—∫∑’ˇªìπµ—∫·¢Áß ªí®®—¬¥—ß°≈à“« àߺ≈„Àâ
°“√√—°…“¥«â ¬«∏‘ ’µ“à ß Ê ‰¡à‰¥âº≈¥‡’ ∑“à ∑˧’ «√

„π™à«ß√–¬–‡«≈“ ‘∫ªï∑Ë’ºà“π¡“ ¡’°“√æ—≤π“‡∑§π‘§°“√√—°…“¥â«¬«‘∏’µà“ß Ê Õ¬à“ß¡“°
°“√√—°…“¥â«¬«‘∏’‰¡àºà“µ—¥ ‡™àπ °“√©’¥·Õ≈°ÕŒÕ≈≈å‡¢â“ àŸ°âÕπ¡–‡√Áߺà“π∑“ߺ‘«Àπ—ß (percutaneous
ethanol injection), °“√∑”≈“¬°âÕπ¡–‡√Áߥ⫬§«“¡√âÕπ (thermal ablation) ·≈–°“√√—°…“¥â«¬«‘∏’
„ à “√‡§¡’∫”∫—¥‡©æ“–∑’Ë·≈–Õÿ¥‡ âπ‡≈◊Õ¥∑Ë’‡≈È’¬ß°âÕπ¡–‡√Áß (transarterial chemoembolization)
‰¥âπ”¡“„™â√—°…“ºâŸªÉ«¬ HCC ¡“°¢È÷πÕ¬à“ß¡“° ´÷Ëß·π«∑“ß°“√√—°…“‡ªìπ°“√√—°…“·∫∫∫√√‡∑“
(palliative measures)(2) ·µ„à πªí®®ÿ∫—π HCC ∑’Ë¡¢’ π“¥°âÕπ‡≈°Á ∫“ß√“¬°ÕÁ “® “¡“√∂À“¬¢“¥‰¥â®“°
°“√√—°…“¥â«¬«‘∏’¥—ß°≈à“« Õ¬à“߉√°Áµ“¡«‘∏’°“√√—°…“¡–‡√Áß HCC ∑Ë’ “¡“√∂À«—ߺ≈„ÀâÀ“¬¢“¥
(curative treatment) ∑Ë’‰¥âº≈¥’∑’Ë ÿ¥§◊Õ°“√ºà“µ—¥ (surgical resection) ·µà¡’ª√–¡“≥√âÕ¬≈– 20

(2)

¢ÕߺŸâªÉ«¬ HCC ‡∑à“πÈ—π∑’ËÕ¬Ÿà„π ¿“æ‡À¡“– ¡µàÕ°“√ºà“µ—¥ „πÕ𓧵®–¡’®”π«πºâŸªÉ«¬∑Ë’‡À¡“– ¡
µÕà °“√º“à µ¥— ¡“°¢π÷È ‡πÕ◊Ë ß®“°¡§’ «“¡µ√–Àπ°— „π°“√µ√«®§¥— °√ÕßÀ“ºªŸâ «É ¬ HCC „π√–¬–‡√¡‘Ë µπâ ¡“°¢π÷È

17

°“√ºà“µ¥— µ—∫√—°…“ HCC
°“√‡≈◊Õ°ºŸâª«É ¬

°“√‡≈◊Õ°ºâŸªÉ«¬∑’ˇÀ¡“– ¡‡ªìπ Ë‘ß ”§—≠∑Ë’ ÿ¥µàÕº≈¢Õß°“√ºà“µ—¥√—°…“  ‘Ëß ”§—≠ ‘Ëß·√°
§◊Õ°“√ ◊∫§âπ¥â«¬°“√µ√«®∑“ß√—ß ’∑’Ë¥’ ‡™àπ ultrasonography, spiral computed tomography
(spiral CT) ·≈– magnetic resonance imaging (MRI) ‚¥¬√«à ¡°—∫°“√©’¥ “√∑∫÷ · ß摇»…„π∫“ß√“¬
´÷Ë߇ªìπ°“√ª√–‡¡‘π®”π«π·≈–µ”·ÀπàߢÕß°âÕπ¡–‡√Áß °“√≈ÿ°≈“¡¢Õ߇ âπ‡≈◊Õ¥¿“¬„πµ—∫ ·≈– ¿“æ
¢Õßµ—∫∑“ß°“¬«‘¿“§ ‡ªìπµâπ(3,4)  Ë‘ßµà“ß Ê ‡À≈à“π’ȇªìπªí®®—¬∑Ë’»—≈¬·æ∑¬åµâÕߧ”π÷ß∂÷ß°“√«“ß·ºπ
°àÕπ°“√ºà“µ—¥ ¢π“¥¢Õß°âÕπ¡–‡√Áß∑’ˇÀ¡“– ¡µàÕ°“√ºà“µ—¥¡—°‰¡à‡°‘π 5 ‡´πµ‘‡¡µ√ ‡æ√“–æ∫«à“
‚Õ°“ ‡°‘¥°âÕπÕË◊πÊ (daughter nodules) √à«¡¥â«¬·≈–‚Õ°“ °“√µ—¥°âÕπÕÕ°‰¡àÀ¡¥®–¡’¡“°
∂â“¢π“¥¡–‡√Áß¡“°°«à“ 5 ‡´πµ‘‡¡µ√(5) Õ¬à“߉√°Áµ“¡®“°°“√»÷°…“æ∫«à“¢π“¥¢Õß°âÕπ¡–‡√Á߉¡à„™à
ªí®®—¬ ”§—≠„π°“√∫հ欓°√≥å‚√§‡æ’¬ßÕ¬à“߇¥’¬« ∫“ߧ√—Èßæ∫«à“¢π“¥¢Õß¡–‡√Áß∑Ë’¡“°°«à“
10 ‡´πµ‘‡¡µ√ °Á¬ß— ‡À¡“– ¡µàÕ°“√º“à µ—¥ ‚¥¬‡©æ“–„π°√≥∑’ ‰Ë’ ¡¡à ª’ í®®—¬ÕË◊π Ê ∑Ë’‰¡à‡À¡“– ¡√«à ¡¥«â ¬
‡æ√“–‰¡à¡’°“√√—°…“·∫∫∫√√‡∑“™π‘¥ÕË◊π∑’Ë„Àâ°“√√—°…“∑Ë’¥’µàÕ¡–‡√Áß°âÕπ„À≠àÊ ‰¥(â 6) ‚¥¬ √ÿª¢âÕÀâ“¡
„π°“√º“à µ¥— ¡–‡√ßÁ µ∫— (hepatic resection) ‡¡ÕË◊ 殑 “√≥“°Õâ π¡–‡√ßÁ ‰¥·â °à ¡–‡√ßÁ µ∫— ∑¡Ë’ °’ “√·æ√°à √–®“¬
‰ª¬—߇ âπ‡≈◊Õ¥ ”§≠— ‡™àπ main portal vein À√◊Õ inferior vena cava À√Õ◊ right atrium, ¡–‡√ßÁ ∑·Ë’ æ√à
‰ª¬ß— Õ«—¬«–ÕË◊π Ê ‡™πà ªÕ¥ µàÕ¡πÈ”‡À≈Õ◊ ß °√–¥Ÿ° ‡ªπì µâπ (™π‘¥¢Õߧ”·π–π” 1)

‚¥¬∑Ë—«‰ª°“√ºà“µ—¥µ—∫∑’ˉ¡à¡’¿“«–µ—∫·¢Áß  “¡“√∂µ—¥‡π◊ÈÕµ—∫ÕÕ°‰¥â¡“°∂÷ß√âÕ¬≈– 70
‡π◊ËÕß®“°ª√–¡“≥√âÕ¬≈– 70-80 ¢Õß¡–‡√Áßµ—∫‡°‘¥„π¿“«–µ—∫·¢ÁßÀ√◊Õ‚√§µ—∫‡√◊ÈÕ√—ß ¥—ßπ—Èπ
°“√ª√–‡¡‘π°“√∑”ß“π¢Õßµ∫— (liver function reserve) ‡ªπì  ßË‘ ∑’ Ë ”§—≠¡“°Õ°’ Õ¬“à ßÀπËß÷ ‡æËÕ◊ À≈°’ ‡≈’¬Ë ß
°“√‡°‘¥µ—∫«“¬À≈ß— º“à µ—¥ (postoperative liver failure) °“√ª√–‡¡π‘ ¥â«¬ Child-Pugh classification
(¿“§ºπ«°µ“√“ß∑’Ë 1) ‡ªπì  ßË‘ ∑’„Ë ™â°π— Õ¬à“ß·æ√Àà ≈“¬(7) „π Child class A ·≈– class B §«√‡À≈◊Õ
‡πÈ◊Õµ∫— (liver volume) Õ¬à“ßπÕâ ¬√âÕ¬≈– 40-50 ·≈– 70-80 µ“¡≈”¥∫—  à«π class C ‰¡ à “¡“√∂
µ¥— µ∫— ‰¥·â ≈–∂Õ◊ «“à ‡ªπì ¢Õâ À“â ¡„π°“√º“à µ¥— µ∫— (™π¥‘ ¢Õߧ”·π–π”1) Õ¬“à ߉√°µÁ “¡‰¡«à “à µ∫— ·¢ßÁ Child
class „¥°Á¬—ß¡’‚Õ°“ °“√‡°‘¥µ—∫«“¬À≈—ßºà“µ—¥‰¥â °“√æ‘®“√≥“ºâŸªÉ«¬‡ªìπ√“¬ Ê ·≈–°“√¥Ÿ·≈ºâŸªÉ«¬
À≈—ߺ“à µ—¥Õ¬à“ß„°≈™â ¥‘ ®ß÷ ¡§’ «“¡ ”§≠— Õ¬“à ß¡“°

18

„π∫“ß ∂“∫—π¡’°“√ª√–‡¡‘π°“√∑”ß“π¢Õßµ—∫‚¥¬«‘∏’Õ◊ËπÊ ‡™àπ „πª√–‡∑»≠Ë’ªÉÿπ¡’°“√„™â Hepatocellular Carcinoma
indocyanine green (ICG) clearance test „π°“√ª√–‡¡‘π°“√∑”ß“π¢Õßµ—∫°àÕπ°“√ºà“µ—¥(8,9)
(·ºπ¿Ÿ¡‘∑Ë’ 1) ‚¥¬æ‘®“√≥“ª√‘¡“≥¢Õß “√ ICG „π‡≈◊Õ¥¿“¬À≈—ß©’¥‡¢â“‡ âπ‡≈◊Õ¥‰ª·≈â« 15 π“∑’
„πºâŸªÉ«¬∑’Ë¡’§à“ bilirubin ª°µ‘·≈–‰¡à¡’¿“«–¢Õß ascites „π¿“«–µ—∫·¢Áß®–¡’°“√¢—∫ “√ ICG
∑“ßπ”È ¥‰’ ¥‰â ¡à¥∑’ ”„Àâ¡’√–¥∫—  “√ ICG „π‡≈◊Õ¥∑’Ë 15 π“∑ ’ ߟ ®÷߉¡‡à À¡“–µÕà °“√ºà“µ¥— µ—∫ÕÕ°‰ª¡“°

·ºπ¿Ÿ¡‘∑Ë’ 1 °“√ª√–‡¡‘π°“√∑”ß“π¢Õßµ—∫‚¥¬ indocyanine green (ICG) clearance test

Ascites

No or controlled Not controlled
Total bilirubin

Normal 1.1-1.5 mg/dl 1.6-1.9 mg/dl >2.0 mg/dl

ICG15 Limited resection Enucleation Not indicated for hepatectomy

Normal 10-19% 20-29% 30-39% >40%
Enucleation
Trisegmentectomy Left/Right Subsegmentectomy Limited resection
Bisegmentectomy hepatectomy

πÕ°®“°πÈ’§«√§”π÷ß∂÷ß ¿“«–¢Õߺ⟪ɫ¬ (performance status) √à«¡¥â«¬‡ ¡Õ ´÷Ëß
 “¡“√∂ª√–‡¡π‘ ‰¥µâ “¡‡°≥±¢å Õß Eastern Cooperative Oncology Group (ECOG) (¿“§ºπ«°µ“√“ß∑Ë’ 3)
æ‘®“√≥“°“√ºà“µ—¥„πºŸâªÉ«¬∑Ë’¡’ scale 0-2  à«πºŸâªÉ«¬∑Ë’¡’ scale 3-4 ‰¡à‡À¡“– ¡µàÕ°“√ºà“µ—¥
(™π‘¥¢Õߧ”·π–π” 1)

ªí®®¬— ¢Õß°“√ºà“µ—¥
¢Õ∫‡¢µ¢Õß°“√º“à µ¥— (extent of resection) ¢Õ∫·π«µ¥— °Õâ π¡–‡√ßÁ (surgical resection)

·≈– perioperative transfusion ‡ªπì 3 ª®í ®¬— À≈°— ∑ Ë’ ”§≠— ∑’Ë¡’°“√»÷°…“°—π¡“¡“°
À≈°— °“√ºà“µ—¥¡–‡√ßÁ µ—∫‡æËÕ◊ À«—ߺ≈À“¬¢“¥ (curation) æ‘®“√≥“¥—ßπÈ’
1. 欓¬“¡„À≥â¢Õ∫·π«µ—¥°âÕπ¡–‡√Áß (extent of resection) Õ¬à“ßπâÕ¬¡’·π«µ—¥∑’Ë¥’

1 ‡´πµ‡‘ ¡µ√ √Õ∫°Õâ π

19

2. 欓¬“¡µ¥— „À‰â ¥âµ“¡°“¬«‘¿“§¢Õßµ∫— (anatomical resection)
3. 欓¬“¡„Àâ¡’°“√‡ ’¬‡≈◊Õ¥√–À«“à ßºà“µ—¥πÕâ ¬∑Ë ’ ¥ÿ ‚¥¬„™â‡∑§π§‘ „π°“√º“à µ—¥µà“ßÊ
‡™πà hepatic vascular inflow occlusion, lowering central venous pressure ‡ªπì µâπ ∑ßÈ— π’ÈÕ“®√«à ¡°∫—
°“√„™‡â §√◊ÕË ß¡◊ՙ૬„π°“√º“à µ¥— ‡™πà intraoperative ultrasound (‡æÕË◊ °“√«“ß·ºπ°“√º“à µ¥— À≈°’ ‡≈¬’Ë ß
‡ âπ‡≈◊Õ¥„À≠ à ”§≠— ), ultrasonic aspirator, argon beam coagulator, vascular stapler ‡ªìπµπâ

°“√ª≈°Ÿ ∂à“¬µ—∫ ”À√—∫¡–‡√Áßµ—∫ (Liver transplantation for HCC)

‡π◊ËÕß®“°ºâŸªÉ«¬¡–‡√Áßµ—∫ à«π„À≠à®–¡“æ∫·æ∑¬å‡¡◊ËÕ‚√§≈ÿ°≈“¡¡“°·≈â«·≈–À√◊Õ
¡’µ—∫·¢Áß√à«¡¥â«¬¡“°®÷߉¡à “¡“√∂√—°…“¥â«¬°“√ºà“µ—¥‰¥â °“√√—°…“‚¥¬°“√ª≈Ÿ°∂à“¬µ—∫
(liver transplantation) ®÷߇ªìπ°“√√—°…“Õ’°«‘∏’ÀπË÷ß´÷Ëß¡’¢âÕ¥’§◊Õ ‡ªìπ°“√µ—¥µ—∫‡¥‘¡ÕÕ°∑È—ßÀ¡¥
≈¥‚Õ°“ °“√°≈∫— ‡ªìπ„À¡à¢Õß‚√§ ·≈–¬ß—  “¡“√∂√°— …“¿“«–µ∫— ·¢Áߥ⫬(16-18)

‡°≥±°å ”Àπ¥ºªŸâ «É ¬¡–‡√ßÁ µ∫— ∑‡’Ë À¡“– ¡µÕà °“√ª≈°Ÿ ∂“à ¬µ∫— (™π¥‘ ¢Õߧ”·π–π” 1)
‰¥·â °à

1. °âÕπ¡–‡√ßÁ °Õâ π‡¥’Ë¬«∑Ë¡’ ’¢π“¥‡≈Á°°«à“ 5 ‡´πµ‘‡¡µ√
2. °âÕπ¡–‡√Áß∑Ë’¡’À≈“¬°âÕπµâÕß¡’®”π«π‰¡à‡°‘π 3 °âÕπ·≈–·µà≈–°âÕπ¡’¢π“¥‡≈Á°°«à“

3 ‡´πµ‘‡¡µ√
3. ‰¡¡à ’ vascular invasion
4. ‰¡¡à °’ “√·æ√°à √–®“¬‰ªÕ«¬— «–ÕËπ◊
ªí®®ÿ∫—π¬—߉¡à¡’°“√»÷°…“·∫∫ prospective randomized controlled trial ‡ª√’¬∫‡∑’¬∫
º≈°“√√—°…“√–À«à“ß°“√ºà“µ—¥µ—∫ (liver resection) °—∫°“√ª≈Ÿ°∂à“¬µ—∫ (liver transplantation)
„πºŸâªÉ«¬¡–‡√Áßµ—∫ ¿“«–¿“¬À≈—ß°“√ºà“µ—¥¢ÕߺŸâªÉ«¬∑È—ß Õß°≈ÿà¡¡’¢âÕ·µ°µà“ß°—π§◊Õ„πºŸâªÉ«¬∑’Ë∑”
liver resection Õ“®®–¡’ª≠í À“µ—∫«“¬ (liver failure) ®“°¿“«–µ∫— ·¢Áß ª≠í À“°“√¥”‡π‘π‚√§µ—∫·¢ßÁ
¡“°¢÷Èπ °“√°≈—∫¡“‡ªìπ´”È (recurrence) ¢Õß‚√§¡–‡√Áß„π‡πÈ◊Õµ—∫ à«π∑’ˇÀ≈◊Õ  à«π„πºâŸªÉ«¬∑Ë’‰¥â√—∫
°“√√—°…“¥â«¬ liver transplantation Õ“®æ∫ªí≠À“°“√‰¡à∑”ß“π¢Õßµ—∫„À¡à (graft dysfunction/
rejection) °“√µ¥‘ ‡™Õ◊È (infection) ·≈–°“√‡°¥‘ „À¡¢à Õß‚√§¡–‡√ßÁ ´ßË÷ ¥”‡ππ‘ ‚√§‰¥‡â √«Á ®“°¬“°¥¿¡Ÿ §‘ ¡âÿ °π—
(immunosuppression)
®“° “‡Àµÿ∑’Ë¡’®”π«πºâŸ∫√‘®“§Õ«—¬«–®”π«ππâÕ¬ ·≈–°“√√Õ√—∫∫√‘®“§µ—∫Õ“®®–π“π
¡“°°«à“ 6-10 ‡¥◊Õπ ¥—ßπÈ—π°“√æ‘®“√≥“°“√ª≈Ÿ°∂à“¬µ—∫„π¡–‡√Áßµ—∫®–‡À¡“– ¡„πºŸâªÉ«¬∑’Ë¡’¿“«–
µ∫— ·¢Áß Child-Pugh class C ∑’ˉ¡à “¡“√∂ºà“µ¥— (liver resection) ‰¥â „πºŸâªÉ«¬∑’Ë°“√∑”ß“π¢Õßµ—∫
¬—ߥՒ ¬àŸ ·≈–¡–‡√ßÁ Õ¬Ÿ„à π lobe „¥ lobe Àπß÷Ë °“√∑” liver resection À√Õ◊ °“√√°— …“¥«â ¬«‘∏’Õ◊πË ∑‡Ë’ ∑’¬∫‡∑à“
πà“®–‡ªìπ°“√√—°…“∑Ë’‡À¡“– ¡‡ªìπÕ—π¥—∫·√° ºâŸªÉ«¬∑’Ë¡’‡πÈ◊ÕßÕ°¢π“¥„À≠à‰¡à§«√∑”°“√ª≈Ÿ°∂à“¬µ—∫
πÕ°®“°®– “¡“√∂ downstage ¡–‡√ßÁ ‰¥‚â ¥¬«∏‘ ’ chemoembolization À√◊Õ local ablation °Õà π

20

Palliative treatment Hepatocellular Carcinoma
Transarterial Chemoembolization (TACE)

°“√√—°…“¥â«¬«‘∏’ TACE ‡ªìπ°“√√—°…“ª√–§—∫ª√–§Õß HCC ∑Ë’„™â∫àÕ¬¡“°∑Ë’ ÿ¥ ‡ªìπ«‘∏’
°“√©’¥¬“‡§¡’∫”∫—¥ ‡™àπ Mitomycin C, 5-Fluouracil, Epirubicin hydrochloride, Cisplatin,
Doxorubicin hydrochloride ‡ªìπµâπ ∑Ë’º ¡°∫—  “√ iodized oil º“à 𠓬 «π‡¢â“‰ª∑“ß hepatic artery
∑”„Àâ¡’°“√©’¥¬“‡¢â“°âÕπ‚¥¬µ√ß πÕ°®“°π’Ȭ—ß “¡“√∂∑”°“√Õÿ¥‡ âπ‡≈◊Õ¥·¥ß∑Ë’‡≈’Ȭ߰âÕπ¡–‡√Áß
‚¥¬°“√„™â gelatin sponge ‡æÕ◊Ë ‡æË‘¡§«“¡‡¢â¡¢πâ ¢Õ߬“‡§¡’„π°âÕπ¡–‡√ßÁ ·≈–µ‘¥§“â ßÕ¬à„Ÿ π°Õâ π¡–‡√Áß
‰¥πâ “π¡“°¢π÷È µ≈Õ¥®π≈¥Õ“°“√¢â“߇§’¬ß¢Õ߬“‡§¡‰’ ¥â

¢Õâ ∫àß™’„È π°“√∑” TACE ‰¥â·°à
1. unresectable HCC from extensive tumor
2. insufficient hepatic reserve postoperatively
3. poor health condition for surgery

¢âÕÀ“â ¡„π°“√∑” TACE ‰¥·â °à
1. complete portal thrombosis
2. major hepatic insufficiency (Childûs class C)
3. severe renal insufficiency
4. biliary obstruction
5. extrahepatic metastasis

°“√∑”≈“¬°Õâ π¡–‡√ßÁ ¥â«¬ “√µà“ß Ê

°“√√—°…“·∫∫ª√–§—∫ª√–§Õß‚¥¬°“√©’¥ “√‡¢â“‰ª∑Ë’°âÕπ‚¥¬µ√ß ‰¡à«à“ºà“π∑“ߺ‘«Àπ—ß
(Percutaneous approach) À√Õ◊ ¢≥–º“à µ—¥ (laparoscopic or open surgery) ¡°’ “√æ≤— 𓇧√ËÕ◊ ß¡Õ◊
 “√µà“ß Ê ·≈–‡∑§‚π‚≈¬’‰ªÕ¬à“ß¡“° ¢âÕ®”°—¥‚¥¬√«¡¢Õß°“√√—°…“§◊Õ®”π«π·≈–¢π“¥¢Õß°âÕπ
 ¿“æ°“√∑”ß“π¢Õßµ—∫·≈–§«“¡·¢Áß·√ߢÕߺ⪟ É«¬ „πª®í ®∫ÿ π— ¡’«‘∏’°“√√—°…“µ“à ßÊ

¢Õâ ∫àß™’È„π°“√√°— …“ 1. ¢π“¥¢Õß°âÕπ¡–‡√ßÁ §«√¡’¢π“¥‡≈Á°°«“à 3 ‡´πµ‡‘ ¡µ√
2. ª√‘¡“µ√°âÕπ√«¡°π— ‰¡‡à °‘π 30% ¢Õߪ√‘¡“µ√µ—∫∑ßÈ— À¡¥

¢âÕÀ“â ¡„π°“√„™â ‰¥·â °à 1. Uncorrectable coagulopathy
2. ¿“«–°“√µ¥‘ ‡™ÈÕ◊ (Sepsis) ∑§’Ë «∫§¡ÿ ‰¡à‰¥â
3. Severe debilitation

21

°“√©¥’ ·Õ≈°ÕŒÕ≈≈‡å ¢“â °âÕπ¡–‡√ßÁ µ—∫ (Ethanol ablation)

«‘∏’°“√©’¥ “√ Ethanol ‡¢â“∑”≈“¬‡´≈≈å¡–‡√Áßµ—∫ “¡“√∂∑”‰¥âßà“¬ ‰¡à¡’§«“¡¬àÿ߬“°
„π‡√◊ËÕ߇§√◊ËÕß¡Õ◊ ·≈– “√ ·≈–‰¥ªâ √– ∑‘ ∏‘¿“æ„π°“√√°— …“¥’

Radio-frequency ablation (RFA)

‡ªìπ°“√√—°…“‚¥¬„™âæ≈—ßß“π§≈◊Ëπ«‘∑¬ÿ‰ª™—°π”„À⇰‘¥‰øøÑ“°√–·  ≈—∫¢÷Èπ¿“¬„π‡´≈≈å
·≈–‡ª≈Ë’¬π‡ªìπæ≈—ßß“π§«“¡√âÕπ ∑”≈“¬‡´≈≈å¡–‡√Áß ‚¥¬√Õ∫„π√—»¡’ª√–¡“≥ 2-5 ‡´πµ‘‡¡µ√
¡–‡√ßÁ ∑’‡Ë À¡“– ¡ ”À√—∫°“√√°— …“¥«â ¬«∏‘ ’πȧ’ «√¡¢’ 𓥇≈Á°°«à“ 3 ‡´πµ‡‘ ¡µ√ ¡’‡πÈ◊Õµ—∫Àâÿ¡Õ¬‚Ÿà ¥¬√Õ∫
Õ¬àŸ≈÷°°«“à º«‘ µ—∫‡°π‘ 1 ‡´πµ‡‘ ¡µ√ ·≈–Õ¬àŸÀà“ß®“°À≈Õ¥‡≈Õ◊ ¥¢π“¥„À≠à ‡™πà hepatic vein, portal vein
‡°‘π 2 ‡´πµ‡‘ ¡µ√

πÕ°®“°πȬ’ —ß¡°’ “√√—°…“¥â«¬«∏‘ °’ “√ÕπË◊ Ê ‡™πà Microwave Ablation, Laser (Neodynium
Yttrium Aluminum Granet) ablation, Cryoablation (liquid nitrogen) ‡ªìπµπâ

·π«∑“ß°“√µ√«®µ¥‘ µ“¡‚√§¡–‡√Áßµ∫—

∑” Imaging ‡™àπ CT, MRI ‡ªìπµâπ ∑°ÿ 3-6‡¥Õ◊ 𠇪ìπ‡«≈“ 2 ªï ®“°π—πÈ ∑°ÿ 1 ªï √«à ¡
°—∫°“√µ√«® AFP ‚¥¬‡©æ“–°√≥’∑Ë’ AFP  ßŸ µÈß— ·µ‰à ¥â√—∫°“√«‘π®‘ ©—¬ µ√«®∑ÿ° 3 ‡¥Õ◊ 𠇪ìπ‡«≈“ 2 ªï
®“°πÈπ— µ√«®∑°ÿ 6 ‡¥◊Õπ

22

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hepatocellular carcinoma resection: an analysis of 165 Childûs A patients. J Surg
Oncol 1997;66:122-6.

14. Lai ECS, You KT, N IOL, Shek TWH. The pathological basis of resection margin for
hepatocellular carcinoma. World J Surg 1993;17:786-91.

15. Asahara T, Katayama K, Itamoto T, et al. Perioperative blood transfusion as a prognostic
indicator in patients with hepatocellular carcinoma. World J Surg 1999;23:676-80.

16. Penn I. Hepatic transplantation for primary and metastatic cancers of the liver.
Surgery 1991;110:726-34.

17. Mor E, Kaspa RT, Sheiner P, Schwartz M. Treatment of hepatocellular carcinoma associated
with cirrhosis in the era of liver transplantation. Ann Intern Med 1998;129:643-53.

18. Bismuth H, Majno PE, Adam R. Liver transplantation for hepatocellular carcinoma.
Semin Liver Dis 1999;19:311-22.

23

·π«∑“ß°“√„™√â ß—  ’√°— …“„π¡–‡√Áßµ—∫

 ¡“§¡√ß—  √’ —°…“·≈–¡–‡√ßÁ «‘∑¬“·Àßà ª√–‡∑»‰∑¬

§≥–ºâ®Ÿ ¥— ∑”

1. ºâ™Ÿ ૬»“ µ√“®“√¬å𓬷æ∑¬™å ≈‡°¬’ √µ‘ ÀÕª√–‡ √‘∞
2. 𓬷æ∑¬å»—°¥Ïæ‘  ‘ ∑‘ Øå π« √‘ ‘
3. 𓬷æ∑¬å¬ß¬ÿ∑∏ §ß∏π“√—µπå

24

·π«∑“ß°“√„™√â ß—  √’ °— …“„π¡–‡√ßÁ µ—∫

°“√„™â√ß—  ‡’ æÕ◊Ë √°— …“ Hepatocelluar Carcinoma ππÈ— ‰¥¡â ’°“√∑¥≈Õß¡“π“π ·µ‰à ¡ªà √– ∫ Hepatocellular Carcinoma
§«“¡ ”‡√®Á ‡πÕË◊ ß®“° ‡πÕ◊È µ∫— ‰¡ à “¡“√∂∑πµÕà ª√¡‘ “≥√ß—  ∑’  ’Ë ßŸ æÕ∑∑Ë’ ”≈“¬ ‡´≈≈¡å –‡√ßÁ ‰¥â ·µ„à πª®í ®∫ÿ π—
‡πË◊Õß®“°‡∑§π‘§¢Õß°“√„Àâ√—ß ’‰¥âæ—≤𓉪¡“°®π “¡“√∂„Àâª√‘¡“≥√—ß ’ Ÿß‡æ’¬ßæÕ∑’Ë®–∑”≈“¬‡´≈≈å
¡–‡√ßÁ ‚¥¬∑‰Ë’ ¡∑à ”≈“¬‡πÕ◊È µ∫— ª°µ¡‘ “°‡°π‘ ‰ª(1-6) ´ßË÷  “¡“√∂„ÀÕâ µ— √“°“√µÕ∫ πÕߢÕß‚√§‰¥ªâ √–¡“≥
60% ·≈–Õ—µ√“°“√Õ¬Ÿà√Õ¥ (median survival) ª√–¡“≥ 10 ‡¥◊Õπ „π°≈ÿࡺ⟪ɫ¬∑Ë’
‰¡à “¡“√∂ºà“µ—¥‰¥â ·µàÕ¬à“߉√°Áµ“¡ °“√«‘®—¬‡°◊Õ∫∑—ÈßÀ¡¥¬—ß¡’°≈àÿ¡µ—«Õ¬à“߉¡à¡“°π—° ·≈–‡ªìπ°“√
»°÷ …“∑‰’Ë ¡„à ™°à “√«®‘ ¬— §«∫§¡ÿ ·∫∫ ¡àÿ (randomized controlled study) ´ßË÷ §«√®–¡°’ “√»°÷ …“«®‘ ¬— ‡æ¡Ë‘ ‡µ¡‘
‡æ◊ËÕÀ“¢Õâ  √ªÿ µÕà ‰ª

Hepatocellular Carcinoma Unresectable, Inoperable Cases
‚¥¬„™â Conformal Radiotherapy
Õ“®æ‘®“√≥“„Àâ√ß—  √’ °— …“„π°√≥’

Unresectable, Inoperable Cases
‚¥¬„™â Palliative Dose Radiotherapy

À¡“¬‡Àµÿ : °“√„™√â ß—  √’ °— …“·∫∫ Conformal Radiotherapy ¬—ß¡¢’ âÕ¡Ÿ≈‰¡à‡æ¬’ ßæÕ
§«√„™‡â æ◊ËÕ°“√»÷°…“«®‘ —¬‡ªπì À≈—°

25

References

1. Matsuzaki Y. Powerful radiotherapy for hepatocellular carcinoma.J Gastroenterol
Hepatol 1999;14:941-945.

2. Cheng JC, Chuang VP, Cheng SH, et al. Local radiotherapy with or without transcatheter
arterial chemoembolization for patients with unresectable hepatocellular carcinoma.
Int J Radiat Oncol Biol Phys 2000;47:435-442.

3. Tokuuye K, Sumi M, Kagam Y, et al. Radiotherapy for hepatocellular carcinoma. Strahlenther
Onkol 2000;176:406-410.

4. Quin J, Feng GS, Vogl T. Combined interventional therapies of hepatocellular carcinoma.
World J Gastroenterol 2003;9:1885-1891.

5. Park HC, Seong J, Han KH, et al. Dose-response relationship in local radiotherapy for
hepatocellular carcinoma. Int J Radiat Oncol Biol Phys 2002;54:150-155.

6. Dawson LA, McGinn CJ, Normolle D, et al. Escalated focal liver radiation and concurrent
hepatic artery fluorodeoxyuridine for unresectable intrahepatic malignancies. J Clin
Oncol 2000;18:2210-2218.

26

·π«∑“ß°“√®¥— √–¬–‚√§¡–‡√Áßµ—∫ Hepatocellular Carcinoma

27

·π«∑“ß°“√®¥— √–¬–‚√§¡–‡√ßÁ µ—∫

°“√®—¥√–¬–‚√§¡–‡√Áßµ—∫¡’À≈“¬√Ÿª·∫∫ ¥—ßµ“√“ß∑’Ë 1-6 ‚¥¬¡’¢âÕ·π–π”„Àâ„™â
TNM classification„π°“√®—¥√–¬–‚√§·≈–√“¬ß“πº≈°“√√—°…“ ·µà “¡“√∂„™â Cancer of the Liver
Italian Program (CLIP) classification ¡“®—¥√–¬–¢Õß‚√§‡æË◊Õª√–‡¡‘π°àÕπ°“√√—°…“·≈–™à«¬
欓°√≥‚å √§

µ“√“ß∑Ë’ 1 Okuda Staging

Tumor size Negative Positive
<50% of liver >50% of liver

Ascites Absent Present
Serum albumin >3 g/dl <3 g/dl

Bilirubin <3 mg/dl >3 mg/dl

Okuda I: No positive factor ; Okuda II: 1 or 2 positive factors; Okuda III: 3 or 4 positive factors.

µ“√“ß∑’Ë 2 The BCLC Staging Classification

Staging Tumor Status Okuda Liver Functional status
PST Tumor Stage
Stage A: early HCC No portal hypertension and
A1 0 Single I normal bilirubin
Portal hypertension and
A2 0 Single I normal bilirubin
Portal hypertension and
A3 0 Single I abnormal biilirubin
Child-Pugh A-B
A 4 0 3 tumors <3 cm l-II Child-Pugh A-B
Stage B : intermediate HCC 0 Large multinodular l-II Child-Pugh A-B
Stage C : advanced HCC 1-2* Vascular invasion or l-II
Child-Pugh C*
extrahepatic spread* lII
Stage D : end-stage HCC 3-4 Any

Stage A and B : All criteria should be fulfilled.
Stage C : At least one criteria * : PST 1-2 or vascular invasion/extrahepatic spread.
Stage D: At least one criteria : PST 3-4 or Okuda stage III/Child-Pugh C.
PST= performance Scale (0: normal activity,1: symptoms but nearly fully ambulatory,2: some bed time,
but needs to be in bed in less than 50% of normal day time,3: needs to be in bed greater than 50% of normal
day time,4: Unable to get out of bed)

28

µ“√“ß∑’Ë 3 French Classification

Weight 0 1 23
yes <80
Karnofsky index1 (%) >80 >50
Serum bilirubin (µmol/l) <50
>2
Serum alkaline-phosphatase (ULN2) <2 >35 Hepatocellular Carcinoma
Serum alpha-fetoprotein (µg/l) <35

Portal obstruction (ultrasonography) no

1 Karnofsky score >80% : complete autonomy of the patient.

2 ULN: upper limit of normal range.

µ“√“ß∑Ë’ 4 TNM classification of hepatocellular carcinomas

Classification Definition
T1 Solitary tumor without vascular invasion
T2 Solitary tumor with vascular invasion or multiple tumors none more than 5 cm
T3 Mulitple tumors more than 5 cm or tumor involving a major branch of the portal or
hepatic vein(s)
T4 Tumor(s) with direct invasion of adjacent organs other than the gallbladder or with

Perforation of the visceral peritoneum

Stage of TNM classification

I T1/N0/M0
II T2/N0/M0
III III A T3/N0/M0

III B T1/N1/M0
T2/N1/M0
T3/N1/M0

IV IV A T4/any N/M0
IV B any T/any N/M1

T = tumor; N = nodes; M = metastasis; N0 = without regional lymph nodes; N1 = with regional lymph nodes;
M0 = without distant metastasis; M1 = with distant metastasis.

29

µ“√“ß∑’Ë 5 Weight of the Six Prognostic Factors in the Chinese University Prognostic Index

Variable Weight (CUPI score)a
TNM
I and II -3
IIIa and IIIb -1
IVa and IVb (reference) 0
Asymptomatic disease on presentation -4
Ascites 3
AFP > 500 ng/ml 2
TB (µmol/L)
0
< 34 (reference) 3
34-51 4
> 52 3
ALP > 200 IU/L

CUPI: Chinese University Prognostic Index; AFP: α-fetoprotein: TB: Total bilirubin; ALP: alkaline
phosphatase.
aCUPI score: Summation of the weights of TNM staging+asymptomatic disease on presentation+
ascites+AFP+TB+ALP (low-risk group, CUPI score < 1; intermediate risk group, CUPI score = 2-7;
high-risk group, CUPI score > 8). For instance, the estimated survival for a patient diagnosed with
TNM stage IIIb hepatocellular carcinoma with ascites, AFP 10,000 ng/mL, TB 20 µmol/L and
ALP 100 IU/L is calculated as follows. (-1)+(0)+(3)+(2)+(0)+(0) = 4. The patient belongs to the
intermediate risk group, with a median survival of 3.7 months (95% confidence interval, 3.1-4.3 months)

µ“√“ß∑’Ë 6 Cancer of the Liver Italian Program (CLIP) classification of hepatocellular carcinomas

Variables Scores 1 2
0 B C
Child-Pugh stage A Multinodular and Massive or
Tumor morphology Uninodular and Extension <50% Extension 50%
Extension <50% >400
AFP (ng/dL) <400 Yes
Portal vein thrombosis No

30

¡–‡√Áß∑Õà πÈ”¥’ Cholangiocarcinoma Cholangiocarcinoma

✦ ·ºπ¿Ÿ¡·‘  ¥ß·π«∑“ß°“√¥·Ÿ ≈√—°…“¡–‡√ßÁ ∑Õà π”È ¥’
✦ ·π«∑“ß°“√µ√«®§¥— °√Õß·≈–«‘π‘®©¬— ¡–‡√Áß∑àÕπ”È ¥’
✦ ·π«∑“ß°“√√—°…“·≈–µ√«®µ‘¥µ“¡¡–‡√Áß∑àÕπ”È ¥’
✦ ·π«∑“ß°“√√°— …“¡–‡√ßÁ ∑Õà πÈ”¥º’ “à π°≈Õâ ß Õà ßµ√«®∑Õà π”È ¥·’ ≈–µ∫— ÕÕà π
✦ ·π«∑“ß°“√√°— …“¥â«¬‡§¡∫’ ”∫¥— „π¡–‡√Áß∑Õà π”È ¥’
✦ ·π«∑“ß°“√„™â√—ß √’ —°…“„π¡–‡√ßÁ ∑Õà π”È ¥’
✦ ·π«∑“ß°“√®¥— √–¬–‚√§¡–‡√ßÁ ∑àÕπ”È ¥’

31

·ºπ¿Ÿ¡·‘  ¥ß

·π«∑“ß°“√¥·Ÿ ≈√—°…“¡–‡√ßÁ ∑àÕπÈ”¥’

™¡√¡»≈— ¬·æ∑¬¡å –‡√Áß (ª√–‡∑»‰∑¬)
™¡√¡»—≈¬·æ∑¬µå ∫— µ—∫ÕÕà π ·≈–∑“߇¥π‘ πÈ”¥’

32

Intrahepatic Cholangiocarcinoma

PRESENTATION WORKUP PRIMARY TREATMENT

Resectable Surgery ● Curative lntent
Unresectableb ● Palliative Intent
● History & Physical Metastasisb
Abdominal pain Suspicious Intrahepatic examination ● Supportive care
Abdominal mass Cholangiocarcinoma ● Ablative therapy
Fever of unknown origin ● Chest X-ray ● Clinical trial
Dyspepsia+weight loss ● U/S
in Native E-sarn* ● CT Scana or MRI ● Supportive care À√Õ◊
● Liver function tests ● Clinical trial À√Õ◊
● Surgical consultation ● Palliative Radiotherapyc
● Consider CEA
● Consider CA 19-9
● Consider AFP

a : æ‘®“√≥“ Spiral CT scan „π ∂“π∑∑’Ë Ë¡’ ’§«“¡æ√âÕ¡
b : Histopathological diagnosis before considering treatment options
c : Radiotherapy 殑 “√≥“‡©æ“– Metastatic Site ‡™àπ Bone metastasis, Brain metastasis

‡æË◊Õ∫√√‡∑“Õ“°“√

* E-sarn : Northern-East ª√–™“°√¿“§µ–«—πÕÕ°‡©¬’ ߇ÀπÕ◊

33

Cholangiocarcinoma

34

Extrahepatic Cholangiocarcinoma

PRESENTATION WORKUP PRIMARY TREATMENT

Resectable Surgical Exploration Unresectableb
Resectable Surgery
● History & Physical examination
● Pain Suspicious ● Chest X-ray Unresectableb Biliary drainage ● Supportive Care À√Õ◊
● Jaundice Extrahepatic ● CT or MRI ● Surgical bypass ● Clinical trial
● Abnormal LFT Cholangiocarcinoma ● Consider Cholangiographya ● Stent
● Obstruction sign ● Consider CEA ● External drainage
● Consider CA 19-9
or abnormality ● Liver function tests
on Ultrasound ● Surgical Consultation
● Bile cytology or Histopathology
● Serologic tests completed

Metastasisb Biliary drainage ● Supportive Care À√◊Õ
● Surgical bypass
● Stent ● Clinical trial À√◊Õ
● External drainage ● Palliative Radiotherapyc

a : Cholangiography ‡™πà MRCP, ERCP or PTC
b : Histopathological diagnosis before considering treatment options
c : Radiotherapy æ‘®“√≥“‡©æ“– Metastatic Site ‡™πà Bone metastasis, Brain metastasis ‡æ◊ËÕ∫√√‡∑“Õ“°“√

·π«∑“ß°“√µ√«®§¥— °√Õß Cholangiocarcinoma
·≈–«π‘ ‘®©—¬¡–‡√Áß∑àÕπÈ”¥’

 ¡“§¡·æ∑¬√å –∫∫∑“߇¥π‘ Õ“À“√·Àßà ª√–‡∑»‰∑¬

§≥–ºâŸ®¥— ∑”

1. √Õß»“ µ√“®“√¬å𓬷æ∑¬åæ‘»“≈ ‰¡â‡√¬’ ß
2. »“ µ√“®“√¬å·æ∑¬Àå ≠ß‘ °√√≥‘°“√å æ√æ—≤π°å ≈ÿ
3. »“ µ√“®“√¬·å æ∑¬åÀ≠‘ß™µÿ ¡‘ “ ª√–¡≈Ÿ  ‘π∑√æ— ¬å
4. æπ— ‡Õ°π“¬·æ∑¬åÕπ™ÿ ‘µ ®Ÿ±–æ∑ÿ ∏‘
5. ºâŸ™à«¬»“ µ√“®“√¬πå “¬·æ∑¬∑å «’»°— ¥‘Ï ·∑π«π— ¥’
6. √Õß»“ µ√“®“√¬å𓬷æ∑¬∏å ’√– æ‘√—™«‘ ∑ÿ ∏‘Ï

35

·π«∑“ß°“√µ√«®§¥— °√Õß
·≈–«‘π®‘ ©¬— ¡–‡√ßÁ ∑Õà πÈ”¥’

∫∑π”

¡–‡√ßÁ ∑Õà πÈ”¥µ’ ∫— „πª√–‡∑»‰∑¬®–‡°¬Ë’ «¢Õâ ß°∫— 欓∏„‘ ∫‰¡µâ ∫— Opisthorchis viverrini (OV)
‡ªπì  «à π„À≠(à 1-4) ºªâŸ «É ¬ «à π„À≠®à –‡ªπì §π„π¿“§µ–«π— ÕÕ°‡©¬’ ߇ÀπÕ◊ ·≈–¿“§‡ÀπÕ◊ ¢Õߪ√–‡∑»‰∑¬(5)
´ßË÷ Õ“®¡’«‘∂™’ «’ µ‘ §≈⓬°π— „π°“√√∫— ª√–∑“πª≈“π”È ®◊¥¥∫‘ ´ßË÷ ¡’µ«— ÕàÕπ欓∏‘„∫‰¡µâ —∫

¡–‡√Áß∑àÕπÈ”¥’ Õ“®·∫àßÕÕ°‡ªπì 2 °≈àÿ¡„À≠Êà (6) §Õ◊
1. Intra-hepatic type (peripheral type) ¡–‡√Áß®–‡°‘¥∑Ë’∑àÕπ”È ¥’¿“¬„πµ—∫ ·≈–¢¬“¬ÕÕ°
 àŸ‡πÈ◊Õµ∫— ¢â“ßÊ ∑”„Àâ¡≈’ °— …≥–‡ªπì °âÕπ¡–‡√Áߧ≈⓬°—∫¡–‡√ßÁ µ—∫™π¥‘ Hepatocellular carcinoma
2. Extra-hepatic type (central type) ¡–‡√Áß®–‡°‘¥∑’Ë∑àÕπ”È ¥’„À≠à µÈ—ß·µà¢È—«µ—∫
(hepatic hilar) ®π∂ß÷ ∑Õà π”È ¥’√à«¡ (common bile duct)  «à πª≈“¬ ∑ßÈ— π‰’È ¡à√«¡¡–‡√ßÁ ∑Ë’ ampula of vater
·≈–¡–‡√Áß∂ÿßπÈ”¥’ ¡–‡√Áß∑àÕπ”È ¥’µ—∫„π°≈àÿ¡π’È®–∑”„À⇰‘¥°“√Õÿ¥µ—π∑àÕπ”È ¥’ ºŸâªÉ«¬®–¡’Õ“°“√µ“‡À≈◊Õß
µ—«‡À≈◊Õß ‡ªìπÕ“°“√π” ‚¥¬æ∫«à“ intra-hepatic type æ∫ 20% extra-hepatic type ∑’˵”·Àπàß
hepatic hilar æ∫ 60% ·≈–æ∫µ”·ÀπàßÕ◊Ëπ·≈–æ∫∑—Èß intra-hepatic ·≈– extra-hepatic bile
ducts 20%

°“√µ√«®§—¥°√Õß¡–‡√Áß∑Õà π”È ¥’ (Cholangiocarcinoma screening)

¿“«–‡ ’ˬß∑Ë’∑”„Àâ¡’‚Õ°“ ‡ªìπ¡–‡√ßÁ ∑Õà πÈ”¥’ (risk factors)
● Primary sclerosing cholangitis(6-7)
● Liver fluke infestration (Opisthorchis viverrini, Clonorchis sinensis)8
● Chronic intra-hepatic duct stone(9)
● Congenital choledochal cyst(10)
● Caloriûs disease(11)
● Multiple biliary papillomatosis(12)
● Thorotrast exposure(13)

36

Primary sclerosing cholangitis ‡ªπì ¿“«–Õ°— ‡ ∫‡√Õ◊È √ß— ¢Õß∑Õà π”È ¥∂’ ß÷ ¿“¬„π·≈–¿“¬πÕ°µ∫— Cholangiocarcinoma
¡’√“¬ß“πæ∫ cholangiocarcinoma ‡°‘¥¢È÷π‰¥â∂÷ß 36%(14) ºŸâªÉ«¬„π°≈àÿ¡πÈ’®–¡’Õ“°“√ª«¥∑âÕß
™“¬‚§√ߢ«“·≈–Õ“°“√§—πµ“¡µ—«·≈–Õ“®¡’Õ“°“√µ“‡À≈◊Õ߉¥â ·µà∂â“¡’Õ“°“√‡À≈◊Õߢ÷ÈπÕ¬à“ß√«¥‡√Á«
µÕâ ßπ°÷ ∂÷ß«à“¡’ cholangiocarcinoma ‡°¥‘ ¢È÷π

Liver fluke infection ‡ªì𠓇Àµÿ¢Õß cholangiocarcinoma ∑Ë’æ∫‡ªì𠓇Àµÿ∑’Ë ”§—≠
∑Ë’ ÿ¥„πª√–‡∑»‰∑¬ æ∫§«“¡™ÿ°„πª√–™“°√¿“§µ–«—πÕÕ°‡©’¬ß‡Àπ◊Õ·≈–¿“§‡Àπ◊Õ °“√«‘π‘®©—¬
cholangiocarcinoma „πª√–™“°√°≈¡àÿ π¡È’ °— µÕâ ßÕ“»¬— Õ“°“√·≈–Õ“°“√· ¥ß §Õ◊ ª«¥∑Õâ ß™“¬‚§√ߢ«“
µ“‡À≈Õ◊ ß µ«— ‡À≈Õ◊ ß ·≈–µ∫— ‚µ §≈”‰¥∂â ßÿ πÈ”¥’ ´ßË÷ ºªâŸ «É ¬ «à π„À≠¡à °— ®–¡°’ “√¥”‡ππ‘ ‚√§∑aË’ dvance·≈«â (15)

°“√µ√«®§—¥°√Õß

„πª√–‡∑»‰∑¬  ÿæ√√≥’ »√’Õ¡— æ√ ·≈–§≥– ‰¥„â ™°â “√µ√«®Õ®ÿ ®“√– æ∫‰¢à欓∏„‘ ∫‰¡µâ ∫—
¡“°°«à“ 10,000 øÕßµàÕ°√—¡ ·≈–√à«¡°—∫°“√µ√«® Antibody µàÕ crude antigen ¡“°°«à“ 1:40
æ∫ —¡æ—π∏å°—∫°“√æ∫ cholangiocarcinoma √à«¡¥â«¬ ‚¥¬¡’ relative risk = 5 „πß“π«‘®—¬πÈ’„™â
ultrasonography ‡ªìπ gold standard „π°“√«π‘ ®‘ ©—¬ cholangiocarcinoma ´Ëß÷ Õ“®‰¡§à àÕ¬·πàπÕπ

Haswell-Elkin ·≈–§≥–(16) ‰¥â∑” community screening ‚¥¬∑”°“√µ√«®Õÿ®®“√–
ª√–™“™π¡“°°«à“ 15,000 §π „πÀ≈“¬®—ßÀ«—¥„π¿“§µ–«—πÕÕ°‡©’¬ß‡Àπ◊Õ À≈—ß®“°π—Èπ‰¥â∑”
ultrasound ∑ÿ°§π∑’Ë¡’‰¢à欓∏‘„πÕÿ®®“√–¡“°°«à“ 6,000 øÕßµàÕ°√—¡¢ÕßÕÿ®®“√–  “¡“√∂µ√«®æ∫
cholangiocarcinoma 15 √“¬ ‚¥¬„™â ERCP ‡ªìπ°“√µ√«®¬◊π¬—π ®“°√“¬ß“πæ∫«à“ºŸâ∑Ë’¡’‰¢à欓∏‘
„∫‰¡âµ—∫„πÕÿ®®“√–¡’§«“¡‡ Ë’¬ß∑Ë’®–‡°‘¥ cholangiocarcinoma ‡ªìπ 4.1 ‡∑à“ ‡¡Ë◊Õ‡∑’¬∫°—∫ºâŸ∑Ë’µ√«®
‰¡àæ∫‰¢à ·≈–°“√µ√«®æ∫‰¢æà ¬“∏‘ ßŸ ¡“°°«à“ 6,000 øÕßµàÕ°√¡— Õÿ®®“√– ®–¡’Õµ— √“‡ ’Ë¬ß 16.5 ‡∑“à
‡¡◊ËÕ‡∑’¬∫°—∫ºâŸ‰¡àæ∫‰¢à欓∏‘„πÕÿ®®“√– ·µàÕ¬à“߉√°Áµ“¡µâÕßµ√«®°√Õߪ√–™“™π®”π«π¡“° ®÷ß®–
æ∫ºŸâª«É ¬ cholangiocarcinoma ´Ëß÷ ‡¡Õ◊Ë §”π«≥§à“„™®â à“¬Õ“®‰¡à§¡âÿ ∑πÿ „π°“√∑”°“√§—¥°√Õß

°“√µ√«®√–¥—∫ Serum alkaline phosphatase, bilirubin ·≈– gamma glutamyl
transpeptidase ¬—߉¡¡à §’ «“¡‰«·≈–‡®“–®ß¡“°æÕ„π°“√µ√«®§¥— °√Õß (17)

°“√µ√«® tumor marker „π serum ∑πË’ ”¡“„™â„π°“√«‘π‘®©¬— cholangiocarcinoma ‰¥â·°à
CEA(18), CA 19-9(18), Ca 125(18), CA 195(19), CA 242(20), DU-PAN(21) 2, IL 6 ,(22) trypsinogen 2 ,(23)
serum sialic acid(24)

CA19-9 ‡ªìπ tumor marker ∑’Ëπ”¡“„™â¡“°∑’Ë ÿ¥ ®–¢È÷π Ÿß„π cholangiocarcinoma
∂÷ß 85% ·≈–∂â“„™‡â °≥±°å “√«‘π‘®©¬— ‚¥¬ CA 19-9  Ÿß°«“à 100 U/ml ®–¡’ sensitivity 75% ·≈–
specificity 80% „π cholangiocarcinoma ∑Ë’‡°¥‘ „πºâªŸ É«¬ primary sclerosing cholangitis ·µÕà ¬à“߉√
°µÁ “¡ CA 19-9 Õ“® Ÿß‰¥â¡“°Ê „πºâŸª«É ¬∑¡Ë’ ’ obstructive jaundice ‚¥¬‰¡à¡’ malignancy ‰¥â ®÷ß¡’
§«“¡®”°¥— ‡¡ËÕ◊ π”¡“„™„â πºâªŸ É«¬∑Ë’¡’¿“«– obstructive jaundice

37

Serum CEA æ∫ Ÿß„π cholangiocarcinoma ª√–¡“≥ 30% ·≈–æ∫„πºŸâªÉ«¬∑’ˇªìπ
¡–‡√Áß™π‘¥ÕË◊πÊ ‰¥âÕ’° ‡™àπ ¡–‡√Áß≈”‰ â ¡–‡√Áß°√–‡æ“–Õ“À“√·≈–µ—∫ÕàÕπ ®÷߉¡à “¡“√∂„™â CEA
‡ªìπ screening test ‰¥â

 «à π Tumor marker µ«— Õπ◊Ë Ê ™«à ¬„π°“√«‘π®‘ ©—¬ºªâŸ «É ¬ cholangiocarcinoma ∑’Ë advance
stage ‡ªìπ à«π„À≠à °“√π”¡“„™â„π°“√ screening ¬—ßÕ¬„Ÿà π√–À«“à ß°“√«®‘ —¬·≈–µ‘¥µ“¡º≈

°“√µ√«® Tumor marker „ππÈ”¥’

¡°’ “√π” Tumor marker ·≈– proteomics(23) À≈“¬µ«— ¡“„™„â π°“√«π‘ ®‘ ©¬— cholangiocarcinoma
‰¥â·°à CEA(25), Mac-2-binding protein(26), CA19-9(27) ·≈– K-ras mutation(28) ‡ªìπµâπ °“√µ√«®
¥—ß°≈à“« ¢â“ßµâπ ∂÷ß·¡â®–¡’§«“¡‰« ·µàµâÕß∑”°“√µ√«®‚¥¬°“√ àÕß°≈âÕ߇æ◊ËÕ‡°Á∫πÈ”¥’¡“µ√«®
´ßË÷ ‰¡ à –¥«°·≈–¬àÿ߬“°∑®’Ë –·π–π”„À‡â ªìπ screening test

À“°¡’°“√æ≤— π“∑ Ë’ “¡“√∂µ√«® Tumor marker ‡À≈“à π’„È πÕÿ®®“√–ºâªŸ É«¬‰¥â ·≈–¡§’ «“¡‰«
·≈–®”‡æ“–¡“° ®–‡ªìπ°“√µ√«®∑πË’ “à ®–„™‡â ªìπ screening test ‰¥„â πÕ𓧵

¢âÕ·π–π”„π°“√µ√«®§¥— °√Õß cholangiocarcinoma „πª√–‡∑»‰∑¬

(™π‘¥¢Õߧ”·π–π” †2B)

‰¡·à π–π”„À¡â °’ “√µ√«®§¥— °√Õß cholangiocarcinoma „πª√–™“™π‰∑¬∑«Ë— ‰ª ‚¥¬°“√µ√«®
‰¢à欓∏‘ √à«¡°∫— °“√∑” screening ultrasonography ‡æ√“–°“√µ√«®‰¡à‡®“–®ßæÕ ·≈–‰¡à§â¡ÿ ∑ÿπ∑µ’Ë âÕß
µ√«®ª√–™“™π®”π«π¡“° ®÷ß®–æ∫ºŸâªÉ«¬ cholangiocarcinoma 1 √“¬ À“°¡’‡§√◊ËÕß¡◊Õ„π°“√§—¥
°√Õß∑Ë’¡’§«“¡‰«·≈–‡®“–®ß¡“°°«à“®÷ߧ«√æ‘®“√≥“∑”°“√ screening ‚¥¬µâÕߥ”‡π‘π°“√∑”
¿“¬„µâ°“√«‘®¬— ‡æËÕ◊ ª√–‡¡‘𧫓¡§¡âÿ ∑ÿπ°àÕπ‡ πÕ·π–‡ªìπ guideline

°“√µ√«® Tumor markers ‡™àπ CA19-9 ·≈– CEA πà“®–„™âµ‘¥µ“¡ª√–™“°√°≈àÿ¡
high-risk ¢Õß cholangiocarcinoma ‡™àπ primary sclerosing cholangitis, Caloriûs disease ·≈–
congenital choledochal cyst ‡ªπì µâπ

°“√«π‘ ®‘ ©—¬¡–‡√Áß∑Õà π”È ¥’
Õ“°“√∑“ߧ≈π‘ ‘°

ºâŸªÉ«¬¡–‡√Áß∑àÕπ”È ¥’µ—∫¡“æ∫·æ∑¬å‡¡Ë◊Õ¡’Õ“°“√·≈–√–¬–¢Õß‚√§¡“°·≈â«À√◊Õ√ÿπ·√ß·≈â«
‡ªπì  «à π„À≠à Õ“°“√¢ÕߺŸªâ «É ¬·∫à߇ªìπ 2 °≈ÿà¡„À≠Êà §◊Õ

38

Intrahepatic (peripheral) type Cholangiocarcinoma

ºâŸªÉ«¬¡’Õ“°“√ª«¥∑âÕß∑Ë’™“¬‚§√ߢ«“·≈–Õ“®√â“«‰ª∑’ˉÀ≈àÀ√◊ÕÀ≈—ß ºŸâªÉ«¬ à«π„À≠à
®–¡’Õ“°“√‡∫◊ËÕÕ“À“√·≈–πÈ”Àπ—°≈¥√à«¡¥â«¬ °“√µ√«®√à“ß°“¬¡—°æ∫µ—∫‚µ ´Ë÷ß∂Ⓡªìπ¡–‡√Áß°≈’∫µ—∫
¥â“π„¥ ®–∑”„Àâ°≈’∫µ—∫¥â“ππ—Èπ‡ÀË’¬« ‡πË◊Õß®“°¡–‡√Áß°¥√—¥‡ âπ‡≈◊Õ¥ ·≈–®–¡’°≈’∫µ—∫¥â“πµ√ߢⓡ‚µ
¢÷πÈ ∑¥·∑π (compensation hypertrophy)(29)

Extrahepatic (central) type

ºâŸªÉ«¬¡’Õ“°“√µ—«‡À≈◊Õßµ“‡À≈◊Õß´÷Ë߇°‘¥®“°°“√Õÿ¥µ—π¢Õß∑àÕπ”È ¥’ ¡—°¡’Õ“°“√§—π·≈–
Õÿ®®“√– ’´’¥ „π°√≥’∑’Ë¡’¿“«–·∑√°´âÕ𠇙àπ ascending cholangitis À√◊Õ acalculous cholecystitis
®–¡’Õ“°“√‰¢â·≈–‡®∫Á ™“¬‚§√ߢ«“(30)

°“√µ√«®√“à ß°“¬®–æ∫¿“«–‡À≈Õ◊ ß µ—∫‚µ ·≈–„π∫“ß√“¬®–¡∂’ ßÿ πÈ”¥‚’ µ√«à ¡¥«â ¬ „πºâªŸ É«¬
√–¬– ÿ¥∑⓬®–æ∫¡–‡√Áß·æ√à°√–®“¬‰ªµàÕ¡π”È ‡À≈◊Õ߇Àπ◊Õ‰Àª≈“√â“ ·≈–°√–®“¬‰ªÕ«—¬«–Õ◊ËπÊ
„π√à“ß°“¬‡™àπ ™Õà ß∑âÕß ªÕ¥ ·≈–°√–¥Ÿ° ‡ªìπµπ⠺⟪ɫ¬∑¡’Ë ’∑àÕπ”È ¥Õ’ ¥ÿ µ—𠇪πì ‡«≈“π“π®–‡°¥‘ µ∫— ·¢Áß
µ“¡¡“ (secondary biliary cirrhosis) ºâŸªÉ«¬∑Ë’¡’√–¥—∫ bilirubin  Ÿß¡“° Õ“®®–√à«¡°—∫°“√µ‘¥‡™È◊Õ
„π∑“߇¥‘ππÈ”¥À’ √Õ◊ ‰¡à°‰Á ¥â ¡’‚Õ°“ ‡°¥‘ ¿“«–‰µ«“¬‡©’¬∫æ≈—π‰¥ â ߟ (31)

°“√µ√«®∑“ß√ß—  ’

Ultrasonography

Intrahepatic type æ∫ solitary mass ∫àÕ¬°«“à multiple mass °âÕπ¡–‡√ßÁ ¡°— ¡’¢Õ∫‰¡‡à √¬’ ∫
·≈–‡ªπì iso À√◊Õ hypoechoic ∂Ⓡªìπ¡–‡√Áß°âÕπ‡≈Á° „π°√≥‡’ ªπì ¡–‡√ßÁ °âÕπ„À≠à ®–‡ªìπ hyper À√Õ◊
mixed echoic

Extrahepatic type ®–æ∫ intra ·≈–/ À√Õ◊ extrahepatic bile duct ‚ªßÉ æÕß(32)

Computed tomography (CT) (33)

Intrahepatic type ®–æ∫ non capsulated inhomogeneous hypodense mass ®–¡’
peripheral enhancement ‡≈Á°πÕâ ¬„π contrast study

Extrahepatic type ®–æ∫√“¬≈–‡Õ¬’ ¥ ·≈–µ”·Àπßà ¢Õß°“√Õ¥ÿ µπ— ∑Õà π”È ¥‰’ ¥™â ¥— ‡®π πÕ°®“°
π’Ȭ—ß “¡“√∂«‘π‘®©—¬ Portal vein ·≈– Hepatic vein encasement ‰¥â¥’°«à“°“√µ√«®
Ultrasound

Magnetic resonance imaging (MRI)(34)

°“√µ√«® MRI ·≈– MRCP ∂◊Õ‡ªìπ°“√µ√«®∑Ë’¥’¡“°„π°“√¥Ÿ¢Õ∫‡¢µ¢Õß¡–‡√Áß·≈–√“¬
≈–‡Õ’¬¥¢Õß∑àÕπ”È ¥’„π¡–‡√ßÁ ™π‘¥ Extrahepatic type ‚¥¬‰¡°à àÕ„À‡â °‘¥¿“«–·∑√°´Õâ π‡À¡◊Õπ ERCP

39

Endoscopic retrograde cholangio-pancreaticography (ERCP)(35)

ERCP  “¡“√∂„Àâ√“¬≈–‡Õ’¬¥¢Õß∑àÕπÈ”¥’‰¥âÕ¬à“ß™—¥‡®π ·≈– “¡“√∂·¬° “‡Àµÿµà“ßÊ
¢Õß∑àÕπÈ”¥Õ’ ¥ÿ µπ— ‰¥Õâ ¬à“ß·¡à𬔠πÕ°®“°πȬ’ ß—  “¡“√∂∑”°“√µ√«® cytology ·≈– tissue pathology
‡æ◊ËÕ¬◊π¬—π°“√«‘π‘®©—¬¡–‡√Á߉¥âÕ¬à“ß·πàπÕπ °“√µ√«® bile cytology ®–„À⧫“¡‰«„π°“√µ√«®æ∫
‡´≈≈å¡–‡√Áß 34-50%(36)

Brushing cytology ¡§’ «“¡‰« 40-60%(37) ·≈– Endoscopic needle aspiration ¡§’ «“¡‰«
83%(38) πÕ°®“°π¬È’ —ß “¡“√∂‡°∫Á bile  ßà µ√«® tumor makers µ“à ßÊ ¥ß— ∑’‰Ë ¥â°≈“à «·≈â«¢“â ßµπâ

Endoscopic ultrasound(39)

 “¡“√∂µ√«® extrahepatic bile duct ·≈– “¡“√∂µ√«®À“·≈–‡®“–¥Ÿ¥‡πÈ◊Õ‡¬◊ËÕ®“°
µàÕ¡π”È ‡À≈◊Õ߇æÕË◊ «π‘ ®‘ ©¬— °“√·æ√°à √–®“¬¢Õß¡–‡√ßÁ ‰¥âÕ°’ ¥â«¬

Positron emission tomography with (18F) -2- deoxy - D - glucose

‡π◊ËÕß®“°‡´≈≈å cholangiocarcinoma  “¡“√∂ uptake glucose ‰¥â¥’¡“° ·µà‰¡à “¡“√∂
metabolize (18F) -2-deoxy-D-glucose ´Ë÷߇ªìπ phosphorelated form ¢Õß glucose ‰¥â ®÷ß∑”„Àâ
¡’°“√§—ËߢÕß “√π’È„π‡´≈≈å cholangiocarcinoma ∑”„À⇪ìπ hot spot „π PET-scan ¡’°“√„™â
PET-scan π’È„π°“√µ√«® cholagiocarcinoma „π Primary Sclerosing Cholangitis ´÷Ë߉¥âº≈¥’¡“°
·µà¬—߉¡¡à °’ “√„™°â “√µ√«®πÈ’„πºŸªâ É«¬ cholangiocarcinoma ∑’ˇ°‘¥®“° Liver fluke

40

¢âÕ·π–π”„π°“√«‘π‘®©—¬¡–‡√Áß∑Õà π”È ¥’
Suspected Cholangiocarcinoma
(™π‘¥¢Õߧ”·π–π” 2B)

● Underlying diseases (risk factors)
● Clinical feature
● Liver function test
● Tumor markers

U/S or CT-scan

Dilated bile duct Liver mass with image characteristic and Cholangiocarcinoma
Positive tumor marker (s)

MRCP/ERCP/PTC* evidence of primary tumor elsewhere***

Typical cholangiography of Cholangiocarcinoma** ‰¡àæ∫ primary æ∫ primary
tumor ∑Ë’ÕπË◊ tumor ∑’ËÕπË◊

Extrahepatic Intrahepatic Liver metastasis
Cholangiocarcinoma Cholangiocarcinoma

* MRCP ‡ªìπ°“√µ√«®∑’Ë¡’§«“¡·¡à𬔪“π°≈“ß·µà¡§’ «“¡ª≈Õ¥¿—¬ Ÿß À“° MRCP ¬—߉¡„à À§â ”µÕ∫®÷ßæ‘®“√≥“
∑” ERCP µàÕ‰ª „π ∂“π∑Ë’™÷Ë߉¡à¡’ MRCP „Àâæ‘®“√≥“ àßµàÕÀ√◊Õæ‘®“√≥“∑” ERCP À√◊Õ PTC ‚¥¬µâÕß
·®âߧ«“¡‡ ¬Ë’ ßµÕà ºªŸâ «É ¬

** µ√«®æ∫ circumferential mass or polypoid intraductal mass causing bile duct obstruction
*** °“√§âπÀ“ primary tumor Õ“®µâÕß„™â°“√´—°ª√–«—µ‘·≈–°“√µ√«®√à“ß°“¬‡ªìπ‡§√◊ËÕß™’Èπ”√à«¡°—∫°“√µ√«®∑“ß

ÀâÕߪØ∫‘ µ— °‘ “√‡∫ÈÕ◊ ßµπâ ‡™àπ CBC, UA, stool for occult blood, chest X-ray ‡ªπì µâπ

41

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43

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44

·π«∑“ß°“√√°— …“ Cholangiocarcinoma
·≈–µ√«®µ‘¥µ“¡¡–‡√Áß∑Õà π”È ¥’

™¡√¡»—≈¬·æ∑¬¡å –‡√Áß (ª√–‡∑»‰∑¬)
™¡√¡»—≈¬·æ∑¬µå ∫— µ∫— ÕÕà π ·≈–∑“߇¥‘ππÈ”¥’

§≥–ºŸâ®¥— ∑”

1. √Õß»“ µ√“®“√¬å𓬷æ∑¬å«™— √æß»å æ∑ÿ ∏ ‘ « — ¥Ï‘
2. 𓬷æ∑¬∏å √’ «≤ÿ ‘ §ŸÀ–‡ª√¡–
3. »“ µ√“®“√¬πå “¬·æ∑¬å∏πæ≈ ‰À¡·æß
4. √Õß»“ µ√“®“√¬å𓬷æ∑¬¥å √‘π∑√å ‚≈àÀ»å √‘ «‘ —≤πå
5. º™Ÿâ ૬»“ µ√“®“√¬å𓬷æ∑¬å≥√ß§å ¢—πµ·’ °«â
6. ¥√.𓬷æ∑¬å¬ß¬∑ÿ ∏ »‘√‘«≤— πÕ°— …√
7. 𓬷æ∑¬°å «‘≠ ≈’≈–«—≤πå
8. 𓬷æ∑¬åÕ“§¡ ™—¬«√’ –«≤— π–
9. æπ— ‡Õ°π“¬·æ∑¬å ∑ÿ ∏®µ‘ ≈≈’ “ππ∑å
10. 𓬷æ∑¬™å ¬— ¬“ ®—π∑√å„ 
11. 𓬷æ∑¬‡å æ™√ ‡°…µ√ ÿ«√√≥
12. º™âŸ ૬»“ µ√“®“√¬å𓬷æ∑¬∫å ÿ≠™Ÿ »‘√‘®π‘ ¥“°ÿ≈
13. √Õß»“ µ√“®“√¬å𓬷æ∑¬ å ÿ√»—°¥Ï‘ ≈≈’ “Õ¥ÿ ¡≈ª‘ î
14. 𓬷æ∑¬å«ÿ≤‘  ‡ÿ ¡∏‚™µ‡‘ ¡∏“

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