Prof. Jianjie Chen's experience in treating liver cancer after surgery with syndrome differentiation and treatment of traditional Chinese medicine

Yang Cheng, Sai-Sai Ni, Jian-Jie Chen

Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China

Keywords:Postoperative liver cancer Clinical experience Chen Jianjie

ABSTRACT By summarizing and analyzing the experience of Professor Chen Jianjie, a famous old Chinese medicine practitioner in Shanghai, using traditional Chinese medicine to treat patients with liver cancer after surgery, it shows Professor Chen Jianjie's idea of prescriptions for medication and exchange learning with colleagues.

EPrimary liver cancer (PLC) is one of the most common lethal malignancies, Hepatocellular carcinoma (HCC) accounts for 85% to 90% of primary liver cancer. Most HCCs are caused by hepatitis B and C viruses, and are closely related to age, gender, geographical area, and ethnic group. It is characterized by insidious onset, rapid progression, strong invasion and high malignancy, so effective monitoring and early diagnosis can lead to therapeutic treatment [1-3]. With the development of medical technology, constantly enrich treatment of liver cancer and the preferred surgical resection, and others, including orthotopic liver transplantation, local ablation, percutaneous arterial chemical embolism, radiation and chemotherapy, and using multiple kinase inhibitor sorafenib for oral treatment [4-5], but these treatments are often difficult to destroy tumor cells, easy to damage normal tissues, and expensive, easy to relapse, and greatly reduce the quality of life of patients [6]. In recent years, traditional Chinese medicine (TCM) has played an important and unique role in the prevention and treatment of liver cancer, and has also carried out clinical and mechanism research, which has a good efficacy in promoting the recovery of the body, reducing side effects, improving the quality of life of patients, and extend the survival time of patients [7-8].

Chen Jianjie, a second-level professor, chief physician, and doctoral supervisor; Shanghai famous Chinese medicine practitioners, Shanghai leading talents; instructor of the inheritance class of famous old Chinese medicine practitioners; dean of the liver disease branch of Shuguang Hospital affiliated to Shanghai University of Traditional Chinese Medicine; the author was fortunate to follow Prof. Jianjie Chen's consultation and learned a lot. Professor Chen Jianjie has applied Chinese medicine to improve the clinical symptoms of patients with liver cancer and improve the quality of life of patients. Now its clinical experience in drug use is introduced as follows for exchange and learning.

1. Etiology and pathogenesis of liver cancer

There is no corresponding name for liver cancer in Chinese medicine, but according to its clinical manifestations and signs, it is classified as "ganji", "jiju", "zhengjia", "xietong", etc.Professor Chen believes that the postoperative recurrence of liver cancer is due to deficiency of qi and blood, damage of zang-fu organs, imbalance of Yin and Yang and other causes leading to the imbalance of qi-blood body fluid, accumulate in the liver, fight each other, and accumulate over time. Patients with liver cancer after the operation, although the physical evil, but the loss of positive qi, the pathogenesis is mostly positive and virtual evil love, the virtual standard. Professor Chen believes that insufficient vital qi is the root of postoperative recurrence of liver cancer, the generation of cancer poison is the key to postoperative recurrence of liver cancer, and qi stagnation, blood stasis and phlegm turbidity are the necessary conditions for postoperative recurrence of liver cancer.

1.1 Insufficient vital qi is the fundamental cause of liver cancer recurrence after surgery

The formation of liver cancer is mainly due to the loss of vital qi and cannot resist the invasion of external evils. The liver injury during the operation of liver cancer loses Qi and blood, damages vital qi, liver and spleen dysfunction caused, the loss of its function, could not be cleared and turbid, and supported the five internal organs and six internal organs, and the limbs and bones, which led to the internal organ dysfunction. Therefore, deficiency of vital qi and disorders of internal organs are the basis of recurrence after operation.

1.2 Qi stagnation, blood stasis, and phlegm turbidity are necessary conditions for recurrence of liver cancer.

Under normal circumstances, the circulation of qi and blood maintains the body's physiological activities and body health. Qi and blood interact with each other in physiology and pathology. Qi and blood metabolize and support the whole body tissue. Qi stagnation can lead to blood stasis, and blood stasis can also cause qi stagnation. Liver cancer surgery consumes Qi and hurts blood, resulting in deficiency of qi and blood and poor fluid operation. Qi stagnation, blood stasis, and phlegm turbidity can form recurrent tumors over time. Therefore, the harm of qi stagnation, phlegm turbidity and blood stasis in the recurrence of liver cancer after surgery should not be ignored.

1.3 The production of cancer poison is the key to the recurrence of liver cancer after surgery

It is a special type of poison caused by long-term stimulation of various pathogenic factors, combination, and intertwining with each other [9], after its formation, block of qi-blood operation, aggravating and qi stagnation, blood stasis and phlegm turbid pathogenic factors of formation, form a vicious circle, which is even more damage [10]. Professor Chen believes that although postoperative recurrence of liver cancer is related to qi stagnation, blood stasis and phlegm turbidity, it is difficult to explain its series of syndromes and complicated clinical symptoms only by qi stagnation, blood stasis and phlegm turbidity. Therefore, the combination of qi stagnation, blood stasis, phlegm turbidity and cancer poison becomes the main pathogenesis, and the endotoxin of cancer is the key to the recurrence of liver cancer [11].

2. Prescription of treatment

Postoperative liver cancer or deficiency syndrome, or empirical, or factors, or no discernible, so it is often difficult to clinical dialectical, therefore, professor Chen stressed in the process of the treatment of liver cancer after surgery, pay attention to the combination of disease and syndrome differentiation, comprehensive four diagnostic information for patients with comprehensive analysis and judgment, analysis the cause of disease and illness, establish corresponding treatment principle. In view of the basic pathogenesis of "positive deficiency, qi stagnation, blood stasis, phlegm turbidity and cancer toxicity", the treatment principle emphasizes to support and dispel evil, attack and remedy. In view of the basic pathogenesis of "positive deficiency, qi stagnation, blood stasis, phlegm turbidity and cancer toxicity", the treatment principle emphasizes to support and dispel evil, attack and remedy.In terms of treatment methods, it is emphasized to invigorate qi and spleen, to support the health of zhongzhou, to detoxify the dampness, and to promote blood circulation.In view of the different clinical manifestations, etiology and pathogenesis of liver cancer after surgery, professor Chen made good use of the experience prescription composed of drug pairs to detoxify decoction and often obtained good clinical efficacy [12].The prescription consists of Atractylodes macrocephala Koidz、Atractylodis Rhizoma、Scutellaria barbarta D.Don、Hedyotis diffusa Willd、Radix salviae miltiorrhizae、Carapax Trionycis、Endothelium Corneum Gigeriage Galli、Arcae Concha、Citri Reticulatae Pericarpium、Pericarpium Citri Reticulatae Viride a composition of five drug pairs.

Atractylodes macrocephala Koidz、Atractylodis Rhizoma：Atractylodes macrocephala Koidz is good at reinforcing spleen, Atractylodis Rhizoma is good at clearing damp, the two are used together to Strengthen the spleen and moisturize.Modern pharmacological studies have found that Atractylodis Rhizom has effects of anti-inflammatory, improving immunity, protecting the liver, and inhibiting the growth of HepG2 cells [13, 14]. Atractylodes macrocephala Koidz can inhibit liver cancer by enhancing the body's immune function [15].

Citri Reticulatae Pericarpium、Pericarpium Citri Reticulatae Viride: Citri Reticulatae Pericarpium is better at drying dampness and reducing phlegm, while Pericarpium Citri Reticulatae Viride is better at dredging liver and breaking qi. Both are used to regulate the ventilator and help the spleen to be healthy. Modern pharmacological studies have found that Citri Reticulatae Pericarpium has antiinflammatory, anti-cancer, antioxidant, and lipid-lowering effects [16], and Pericarpium Citri Reticulatae Viride has extensive pharmacological and anti-cancer effects on cardiovascular, digestive, and respiratory systems [17].

Scutellaria barbarta D.Don、Hedyotis diffusa Willd: Both branches have a cold nature, and Scutellaria barbarta D.Don has the effect of breaking blood through the liver; Hedyotis diffusa Willd has the function of eliminating spleen and dissolving knots. In order to prevent the heat poisoning in the liver, the anti-cancer and anti-virus effect can be achieved. Modern pharmacological research found that Scutellaria barbarta D.Don has pharmacological effects such as antitumor, immune enhancement, and liver protection [18]; Hedyotis diffusa Willd has anti-tumor, anti-inflammatory, antibacterial, antioxidant, and immune-improving effects [19].

Arcae Concha、Endothelium Corneum Gigeriage Galli: Endothelium Corneum Gigeriage Galli taste sweet flat, stomach digestion; Arcae Concha salt flat, eliminating phlegm and removing blood stasis.Liver disease patients often spleen deficiency, as "golden chamber synopsis · zang-fu organs and channels successively disease pulse syndrome" said: " See the disease of the liver, know that the liver transmits the spleen, and take the spleen first".Therefore, it is advisable to protect the spleen and stomach and maintain the normal physiological functions and characteristics of the spleen and stomach.Modern pharmacological studies have found that Arcae Concha has a protective effect on acute gastric ulcer, significantly increasing the levels of SOD and VEGF in rat serum, and decreasing the levels of MDA in rat serum [20]. Endothelium Corneum Gigeriage Galli has pharmacological effects such as anti-oxidation and improvement of gastrointestinal function [21].

Radix salviae miltiorrhizae、Carapax Trionycis: Radix salviae miltiorrhizae is bitter and slightly cold, and the effect of promoting blood circulation and removing blood stasis is remarkable; Carapax Trionycis salt and cold, the effect of soft liver dispersal is very good.The two invigorate the blood and remove the blood stasis, the soft and firm dispersal, the visible evil is removed, the invisible evil is eliminated.Modern pharmacological studies have found that Radix salviae miltiorrhizae has liver-protecting, anti-cirrhotic and anti-HCC effects [22], and Carapax Trionycis can inhibit the proliferation of HSC-T6 induced by TGF-β1 and has an anti-fibrotic effect [23].

The prescription is simplified. On the basis of recuperating the spleen and stomach, complementary with dredge liver line gas, clear heat detoxification, huoxue soft firm loose, can prevent the disease to worsen further.

3. Examples of medical records

Case 1: Chen xx, male, 48 years old, external hospital examination in June 2015 showed that the right lobe of the liver was occupied.Laparoscopic partial resection of the right lobe of the liver (4.1× × 3.5 ×× 3.2 cm in size) was performed in a third-class a hospital in this city.Pathological examination revealed primary liver cancer with a differentiated hepatocellular carcinoma (HCC) in segment V of the right lobe.On October 14, 2015, the patient came to the outpatient clinic for treatment due to side pain and fatigue. Laboratory examination showed that the liver function was ALT186U/L, AST123U/L, TB36.9umol/L.HBV-DNA: 2.58×106, HBV markers: HBsAg(+), HBeAg(-), anti-HBc (+);AFP: 1390.6 ng/ml.He has a history of chronic hepatitis B and is now taking ETV for antiviral treatment. At this time: Flank and ribs dull pain, weakness, dry mouth bitter, eyes acerb, stool thin, normal urine, more dreams, purple dark tongue, thin white tongue coating, veins fine strings.Western medicine diagnosis: liver cancer after surgery;Diagnosis in traditional Chinese medicine: flank pain (stagnation of liver qi and stagnation of congestion). To invigorate the spleen and regulate qi, clear heat and detoxify, invigorate the blood.

Prescription: Erzhu Jiedu Decoction,Atractylodes macrocephala Koidz15g、Atractylodis Rhizoma15g、Scutellaria barbarta D.Don10g、Hedyotis diffusa Willd10g、Radix salviae miltiorrhizae12g、Carapax Trionycis9g、Endothelium Corneum Gigeriage Galli9g、Arcae Concha30g、Citri Reticulatae Pericarpium9g、Pericarpium Citri Reticulatae Viride9g etc.Take 14 doses, decoction with water, 1 dose /d, half an hour after breakfast and dinner.

Another oral antiviral: entecavir 0.5mg/ time, 1 time/day, oral.Tell more rest, diet light, avoid spicy stimulation.

Review after 1 month: liver function ALT127U/L, AST100U/L, TB31.9umol/L, AFP: 1202.7 ng /ml.After taking the upper part of the symptoms improved, continue the upper part of the treatment. Entecavir continued to serve.

From October 2015 to October 2019, the patient has been taking antiviral and traditional Chinese medicine treatment in the outpatient department, with regular review. In December 2016, the patient underwent physical examination: abdominal CT showed no signs of recurrence and metastasis.Liver function was normal, AFP 358.2ug/mL.On October 26, 2017, laboratory examination showed that HBV DNA was below the detection limit, AFP 45.8ug/mL, and liver and kidney function and blood routine were normal.Abdominal MRI showed no signs of recurrence and metastasis.At present, the patient's current condition is stable in the follow-up, which indicates that the combination of TCM syndrome differentiation and antiviral therapy for liver cancer can improve the patient's clinical symptoms and significantly improve the patient's quality of life.

Note: liver cancer postoperative damage qi and blood, qi stagnation, blood stasis, phlegm turbidity, cancer toxicity endogenous.Professor Chen believes that this patient was diagnosed with liver cancer shortly after surgery. According to the clinical symptoms of the patient, the medication is mainly for strengthening the spleen, protecting the stomach, regulating qi, detoxifying, promoting blood circulation, and strengthening the body. Therefore, with the addition and subtraction of Ershu Jiedu Decoction, combination of various medicines, support the vital qi and dispel evil qi, Attack and complement sharing, strengthen the spleen and protect the stomach, soothe the liver and regulate qi, clearing away heat and detoxifying, promoting blood circulation and softening strength. The patient has been in surgery for more than 4 years since 2015, and has a high quality of life and significant clinical efficacy.

4. Conclusion

In summary, professor Chen jianjie's application of ershu jiedu decoction has a good clinical effect on improving the clinical symptoms and quality of life of patients with liver cancer after surgery.Although the mechanism of TCM in the treatment of liver cancer is relatively complex, with the development of TCM modernization, the research on the anti-liver cancer mechanism of TCM is becoming more and more clear. I believe that TCM will give full play to its unique advantages in the treatment of liver cancer.