2026年欧洲肝病学会年会（EASL 2026）在西班牙巴塞罗那隆重召开，这场国际肝病领域的顶尖学术盛会，汇集了全球众多专家学者，共同探讨肝病诊疗的前沿进展与临床难题。肝细胞癌（HCC）合并免疫介导性肝损伤，是当前临床诊疗中十分棘手且备受关注的问题。会议期间，本刊特别专访了意大利博洛尼亚大学Francesco Tovoli教授。Tovoli教授结合临床实际，围绕该类肝损伤的临床诊疗要点展开交流，分享专业思考与实践经验，希望能为广大临床医师开展相关工作提供参考与启发。

《国际肝病》

HCC患者的免疫介导性肝损伤具备怎样的发病特征，同时它会对肿瘤进展、患者整体预后产生哪些具体影响？

Tovoli教授：免疫相关性肝损伤轻症仅表现为肝酶升高，重症可进展为肝功能失代偿，危重病例还会出现腹水、肝性脑病。目前该损伤对肿瘤进展的影响尚未完全明确，若临床处置不当，会直接影响患者生存。一方面，若未接受治疗或治疗力度不足，会诱发肝功能失代偿，改变患者的预后走向；另一方面，若治疗过度，则可能引发皮质类固醇与免疫抑制相关的并发症。

Hepatology Digest: What are the clinical characteristics of immune-mediated liver injury in HCC patients? In addition, what specific impacts does it exert on tumor progression and the overall prognosis of patients?

Prof. Tovoli: Mild cases of immune-related liver injury typically present with as isolated elevation of liver enzymes, while severe cases may progress to hepatic decompensation, including ascites and hepatic encephalopathy. At present, the direct impact of such liver injury on tumor progression and outcomes remains incompletely understood. However, improper clinical management might affect patient survival. On one hand, inadequate or absent treatment of severe cases may trigger hepatic decompensation and alter the prognostic trajectory of patients. On the other hand, overtreatment of mild cases may lead to complications associated with corticosteroids and immunosuppression.

《国际肝病》

肝癌患者病情复杂，肝损伤成因多样。临床诊疗过程中，我们该如何精准区分免疫介导的肝损伤，与肿瘤本身病变、抗肿瘤治疗相关肝损伤？主要依靠哪些依据完成鉴别判断？

Tovoli教授：肝细胞癌患者属于免疫相关性肝损伤鉴别诊断中的特殊人群。这类患者大多合并基础性肝硬化，且肿瘤原发病灶位于肝脏内部，随着病情进展，肿瘤会侵犯周边肝实质、肝脏血管及胆管，进而引发肝酶、胆红素升高等肝功能异常表现。

不过，实验室检查出现的这类指标异常，并非均由肿瘤因素导致，也可源于各类非肿瘤诱因，比如基础肝病引发的肝酶生理性波动、与门静脉高压相关的非癌性门静脉血栓等。因此，临床针对此类患者需开展多维度鉴别诊断，其中影像学检查发挥着至关重要的作用。

临床实操中，无需通过CT、MRI等影像学手段对患者进行全面重新分期，该方式可行性较低。而床旁超声（point of care ultrasound）具备便捷、高效的优势，可快速识别血管侵犯、胆管侵犯等并发症。尤其针对重症患者，影像学检查能够有效辅助临床完成鉴别诊断，为后续规范化治疗提供精准指导。

Hepatology Digest: HCC presents complex conditions with diverse causes of liver damage. In clinical practice, how can we accurately distinguish immune-mediated liver injury from liver injury caused by tumor lesions themselves and anti-tumor therapies? What are the main bases for differential diagnosis?

Prof. Tovoli: Patients with hepatocellular carcinoma are a special population in which the differential diagnosis of immune-related liver injury is particularly complex. Most of these patients have underlying liver cirrhosis, and the main tumor is located within the liver. As the tumor progresses, it may invade the adjacent liver parenchyma, hepatic blood vessels and bile ducts, resulting in abnormal liver function such as elevated liver enzymes and bilirubin. In addition, non-tumor portal vein thrombosis may occur as a complication of cirrhosis, further complicating the differential diagnosis.

Nevertheless, abnormal laboratory indicators are not always attributed to tumor lesions. They may also stem from non-neoplastic factors, including physiological fluctuations of liver enzymes due to underlying liver diseases and non-neoplastic portal vein thrombosis related to portal hypertension. Therefore, a multi-dimensional differential diagnosis is required for such patients, among which imaging examinations play a vital role.

In routine clinical practice, it is not always feasible to re-stage patients comprehensively via CT or MRI. Point-of-care ultrasound features convenience and high efficiency, that may rapidly identify complications such as vascular invasion and biliary invasion. Particularly for critically ill patients, imaging examinations effectively assist differential diagnosis and guide subsequent standardized treatment.

《国际肝病》

明确免疫介导性肝损伤带来的临床提示后，在后续诊疗工作中，我们应当采取怎样的个体化管理方案？如何在开展抗肿瘤治疗的同时，合理防控此类肝损伤，保障治疗安全性？

Tovoli教授：临床诊疗首要原则是区分肝损伤的病情严重程度，将仅存在转氨酶升高、单纯肝酶升高的轻症患者，与合并肝衰竭的重症患者鉴别开来。重症免疫介导性肝损伤虽临床少见，但必须及时开展积极干预。临床多数患者仅为轻症，仅表现为单纯肝酶升高，针对这类患者，切勿仓促使用皮质类固醇治疗，需先完成精准的鉴别诊断。即便经评估确需采用皮质类固醇治疗，在非绝对必要的情况下，也应避免使用超高剂量激素。

与此同时，需为患者开展高频次的实验室随访检查，根据病情动态调整，实施个体化减量（tapering）方案，在患者病情条件允许时逐步减量，保证患者仅接受病情所需的最低有效激素剂量。这一管理方式能够有效规避因过度免疫抑制、过度治疗引发的各类并发症。

Hepatology Digest: With a clear understanding of the clinical implications of immune-mediated liver injury, what individualized management strategies should be adopted in subsequent clinical work? How to prevent and control such liver injury rationally while delivering anti-tumor treatment and ensure treatment safety?

Prof. Tovoli: The primary clinical principle is to stratify the severity of liver injury, differentiating mild cases with isolated elevated transaminases from severe cases complicated with liver failure. Though severe immune-mediated liver injury is relatively rare, timely and aggressive intervention is mandatory in these occasions. On the other hand, most patients present with mild injury characterized solely by elevated liver enzymes. For these individuals, corticosteroid therapy should not be initiated hastily before completing differential diagnostic workup. Even when corticosteroid treatment is deemed necessary, ultra-high-dose regimens should be avoided unless absolutely required.

Meanwhile, high-frequency laboratory follow-up tests should be arranged for patients. Treatment plans need dynamic adjustment alongside individualized tapering protocols. Glucocorticoids should be gradually reduced as the patient's condition allows, ensuring that patients receive the minimum effective dose required for disease control. This management approach can effectively prevent various complications caused by excessive immunosuppression and overtreatment.

（来源：《国际肝病》编辑部）

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