Hepatocellular Carcinoma 3

8/10/2019 Hepatocellular Carcinoma 3

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LIVER TUMOUR

OLEH :

Dr.HANS MARPAUNG, SpB,FICS


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ANATOMYThe liver weighs 15002000 g and so is the largest gland inthe human body.Traditionally, the insertion into the liver of the falciformligament was thought to divide the liver into a right and aleft lobe.

In 1981, Couinaud provided a more accuratedescription of the segmental anatomy of the liverThe true division into a right and a left lobe lies inthe main lobar fissure, an oblique plane passing from the

gallbladder fossa anteriorly to the bed of the inferior venacava posteriorly (Cantiles line).


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Structure


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Tumours in the liver can be benign ormalignant.

Malignant tumours can be primary or,more commonly, secondary ( metastatic).


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MALIGNANT PRIMARY LIVER NEOPLASMS

The most common malignant primary tumors areHepatocellular Carcinoma (HCC) or Hepatoma andCholangiocarcinoma.

HCC arises from the hepatocytes and cholangiocarcinomafrom the epithelium of the intrahepatic biliary tract.

The tumor, referred to as Hepatoblastoma,occurs almost exclusively in the first 3 years of life.


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HEPATOCELLULAR CA Epidemiology

One of the most common tumors in the world & 3rd

mortality

Usually arise in the setting of chronic viral hepatitisor cirrhosissecondary to other causes

Earlier peak incidence in Asia and Africa than in

Western countries(1~2 decades)

More common inmenthan in women ( 4:1)


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Stomach2 0%

Breast

2 0%

Colorectal

2 0%

Liver

13%

Lung2 7%

The Global PerspectiveThe Big Five Cancers


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The Major Etiological Factors

Chronic hepatitis - types B or C

Cirrhosis/chronic liver disease ofany type

Aflatoxin exposure

Males, increasing age


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Cirrhosis

Immature, non-functional cells


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Major Risk Factors

El-Serag, H.B. and K.L. Rudolph, Hepatocellular carcinoma: epidemiology and molecular carcinogenesis.Gastroenterology, 2007. 132(7): p. 2557-76.Brunetto M.R., O.F., Koehler M., et al., Effect of interferon-alpha on progression of cirrhosis to hepatocellular carcinoma: a retrospective cohort study.

International Interferon-alpha Hepatocellular Carcinoma Study Group.Lancet, 1998. 351(9115): p. 1535-9.

HBV 5-15 fold increased risk 70-90% of cases occur in setting of

cirrhosis Treatment does NOT decrease risk Risk highest in carriers and lower in

immuneHCV 1-3% of cirrhotic patients develop

HCC Treatment seems to decrease risk

Co-infectionAflatoxins (Aspergillus fumigatus)

4 fold increased risk HCCAlcohol >50-70g/day No link to direct carcinogenic effect Synergistic with HCV and HBV

Nonalcoholic Steatohepatitis?


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8% - High

2-7% - Intermediate


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Clinical Staging

Numerous staging systems exist and NOCONSCENSUS E.g. TNM, Okuda, CLIP, and BCLC

Incorporate 4 determinants of survival Severity of underlying liver disease Size of tumor Extension of the tumor into adjacent structures Presence of metastases

Primary staging should be clinical stagingSecondary staging with the AJCCTNM


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Child-Pugh classification

CriteriaTotal Serum Bilirubin Bilirubin3 mg/dl: 3 points

Serum Albumin

Albumin >3.5 g/dl: 1 point Albumin 2.8 to 3.5 g/dl: 2 point

Albumin


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Okuda stageTumor size (< or > 50% of the liver)

Ascites (absent or present)

Bilirubin (< or > 3)Albumin (< or >3)

Natural history without treatment

Stage(0 pt) : 8 monthsStage(1-2 pt) : 2 months

Stage(3-4 pt) : less than 1 month


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CLIP ScoreChild-Pugh

A 0

B 1C 2

Tumor morphology

Uninodular and extension 50% 0

Multinodular and extension 50% 1

Massive or extension >50% 2

AFP

400 1

Portal Vein ThrombosisNo 0

Yes 1

Prospective validation of the CLIP score: A new prognostic system for patients with cirrhosis and hepatocellular carcinoma. Hepatology 2000; 31:840


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TNM - AJCCStage I T1 N0 M0 55% 5 yr survival

Stage II T2 N0 M0 37% 5 yr survival

Stage IIIA T3 N0 M0 16% 5 yr survival

IIIB T4 N0 M0

IIIC Any T N1 M0

Stage IV Any T Any N M1

T definitions

T1solitary nodule without vascular invasion

T2solitary tumor with vascular invasion or multiple nodules all 5cm, or tumor with major vasculature invasion

T4Tumor with invasion of adjacent organs

AJCC Cancer Staging Manual, Sixth Edition (2002) published by Springer-Verlag New York, Inc


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Tumor DetectionInitially, hard to detectTo screen high-risk patientsperiodically

* Infectious hepatitis or family history of HCC

Surveillance tools for HCC

*AFPblood test & ultrasound examination

Symptoms

* Painless mass in right hypochondriac region.

* Liver is hard, irregular and often massively enlarged

* Weight loss, fever, nausea, weakness, tenderness,

jaundice.

* Ascites (40%) often it is massive, splenomegaly and

features of portal hypertension may be present.


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Diagnosis

Detection of mass in cirrhotic liver is highly suspiciousfor hepatocellular carcinoma.

Diagnostic strategies are dependent on diameter

sizes.

>2 cm in diameter, 1-2 cm in diameter and


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Spread of Tumour

Lymphatic spread: it can spread to other part of liverthrough lymphatic within the liver, to the lymph nodesin the porta hepatis and other abdominal lymph nodeslater. Often spread occurs directly to cisterna chyli.

Blood spread: To lung, bones and adrenals often canoccur.

Direct infiltration: To diaphragma and neighbouringstructures.


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Diagnosis

https://www.aasld.org/


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Tumour Detection


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Evaluation

Prognosis depends on 2 separate factors

-Tumor: size, number, vascular invasion, extrahepatic disease

-Liver disease: Child-Pugh,Perfomance statusLesion imaging, lab results, patients age, overall health

(underlying cirrhosis, involvement of both hepatic lobes,

distant metastasislung, brain, bone , adrenal gland)

Imaging procedure

: Ultrasound, CT, Hepatic angiography, MRI, PET


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BCLC(Barcelona-Clinic Liver Cancer staging)

4 levels of staging

- A. Early stage(Child A, single lesion 2)

- D. Terminal stage


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BCLC(Barcelona-Clinic Liver Cancer staging)


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Initial Management

Patients presenting acutely withdecompensated liver faillure require

specialist hepatological management.Management principles includeattention to nutrition, careful fluid

balance and treatment of portalhypertension


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Treatment Strategies for HCC

Surgical resection Liver transplantation

Radiofrequency ablation

Percutaneous ethanol/acetic acid injection

Transarterial embolisation/Transartrialchemoembolisation (TACE).

Microwave/ cryoablation

Transarterial radiotherapy

Adjuvant systemic chemotherapy

etc


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Surgical Resection (Tumor Removal)

If patients can withstand surgeryand have enough liver

reserve(up to 5 in diameter with minimal blood

invasion)

The method choice and the extent of the resection

depend on the residual function of the remaining liver

Can remove up to 70% of a cancerous liver ( if no or

mild fibrosis)

Liver canregeneratein about 2~6 weeks following

surgery


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Pre

% TLV = 33%

Left Lobe

Volume = 608 cm3

Post

% TLV = 51%

Left Lobe

Volume = 912 cm3

PV Embolization

Treatment of hepatocellular injury (AST)

with PEG interferon in the interval (10 weeks)


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Surgical Resection(Tumor Removal)

Left hemihepatectomy : segments,and

Extended left hemihepatectomy: segments,,,and

Right hemihepatectomy : segments,,and

Extended right hemihepatectomy : segments ,,,

and

Left lobectomy : segmentsandRight lobectomy : segments~


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FIGURE . Hepaticresections. The type ofliver resection performeddepends on the type andextent of the pathology.(Adapted with permission fromSchwartz SI, ed. Principles ofSurgery. 6th ed. New York:McGraw-Hill, Inc., Health

ProfessionsDivision, 1994.)

H t ll l C i


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Hepatocellular Carcinoma

Treatment Paradigm

HCC

Locoregional therapy?

Systemic therapy

Surgically resectable ?

Yes

No

No

Arterial chemo embolisation

Radiofrequency ablation

Alcohol injection

Internal radiationetc

Resection

Yes


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Liver Transplantation

Excellent curefor most patients, but limited organ supply

makes this option unattainable

Benefit for small, unresectable HCC and cirrhosis

Indications: the patient is not a liver resection candidate

: the tumor(s) is smaller than or equal to 5 in diameter

: there is no macrovascular invlovement

: there is no identifiable extrahepatic spread of tumor to

surrounding LN, abdominal organs, or bone


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Liver Transplantation

UNOS( the United Network for Organ Sharing)

* Eligibilitycriteria : a single hepatoma


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Documents

Hepatocellular Carcinoma 3