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Training Module 5 – Version 1.1
For Internal Use Only
®
Liver Cancer
Training Module 5 – Version 1.1
For Internal Use Only
®
Liver Cancer
Training Module 5 – Version 1.1
For Internal Use Only
®
Liver Cancer
Primary Liver Cancer
Secondary Liver Cancer
Hepatic neuroendocrine metastasis
Training Module 5 – Version 1.1
For Internal Use Only
®
Liver Cancer
Primary Liver Cancer
Secondary Liver Cancer
Hepatic neuroendocrine metastasis
Training Module 5 – Version 1.1
For Internal Use Only
®
Primary Liver Cancer
Incidence and mortality
Worldwide primary liver cancer is considered the fifth most significant cancer in terms of number of cases (437,000 or 5.4% of new cancer cases)
It is the fourth most significant in terms of mortality (427,000 deaths or 8.2% of the total)
The small difference in incidence and mortality reflects the extremely poor prognosis of primary liver cancer
D.Parkin et al, CA Cancer J.Clin 1999: 49(1) 33-64
Training Module 5 – Version 1.1
For Internal Use Only
®
Primary Liver Cancer
hepatocellular carcinoma (HCC)
cholangiocarcinoma
haemangioendothelioma
haemangioblastoma
angiosarcoma
primary sarcoma
HCC is the most common primary malignancy of the liver (85%)
Types of primary liver cancer:
Training Module 5 – Version 1.1
For Internal Use Only
®
Primary Liver Cancer
hepatitis virus infections (HBV, HCV)drugs (mostly alcohol and tobacco)mycotoxins or phytotoxinsliver diseasesmetabolic diseaseschemical agents and inorganic substancesmedicationionizing radiation
HCC - Risk factors:
Training Module 5 – Version 1.1
For Internal Use Only
®
Primary Liver Cancer
pain in the upper abdomenbloating, flatulenceanorexia, nauseaweight lossfatigue, weaknessstool irregularities
HCC - Symptoms:
HCC develops without subjective complaints and is therefore usually detected (too) late!
Complains - if any - are very varied:
Training Module 5 – Version 1.1
For Internal Use Only
®
Primary Liver Cancer
feversubicterusasciteslatent encephalopathyarterial murmurtenderness upon pressurepalpable tumourperihepatic friction
HCC - Clinical findings:
Training Module 5 – Version 1.1
For Internal Use Only
®
Primary Liver Cancer
laboratory findings (incl. alpha-fetoprotein=AFP)
sonography
computer tomography
percutaneous fine-needle biopsy (FNB)
laparoscopy
HCC - Diagnosis:
Training Module 5 – Version 1.1
For Internal Use Only
®
Primary Liver Cancer
HCC - Diagnosis – Computer Tomography (CT):
Training Module 5 – Version 1.1
For Internal Use Only
®
Primary Liver Cancer
HCC - Diagnosis - Laparoscopy:
Training Module 5 – Version 1.1
For Internal Use Only
®
Primary Liver Cancer
HCC - Prognosis:
The prognosis is determined by the tumour mass and its speed of growth at the time of diagnosis.
Signs of poor prognosis are:
considerable size of tumour (>5cm)
infiltrative growth
multilocular growth
metastatic spread
Training Module 5 – Version 1.1
For Internal Use Only
®
Primary Liver Cancer
HCC - Prognosis:
The natural course of disease shows an average survival rate of 5 months (2-8 months).
Some 3% of patients survive for 5 years
Training Module 5 – Version 1.1
For Internal Use Only
®
Liver Cancer
TNM staging of primary liver cancer:
T0 Disease freeT1 <2cm, no vascular invasionT2 <2cm, vascular invasion
or: >2cm, no vascular invasionT3 >2cm with vascular invasion
or: multiple lesionsT4 multiple lobes, macrovascular invasion
N0 no regional lymph node involvementN1 regional lymph node involvement
M0 no metastasisM1 metastasis
Training Module 5 – Version 1.1
For Internal Use Only
®
Primary Liver Cancer
HCC – Staging:
0 points 1 point
Liver invasion <= 50% > 50%
Ascites no yes
Bilirubin <= 3mg/dl > 3mg/dl
Albumin > 3g/dl <= 3g/dl
stage 1: 0 points, stage 2: 1-2 points, stage 3: 3-4 points
K.Okuda et al., 1993
Training Module 5 – Version 1.1
For Internal Use Only
®
Primary Liver Cancer
HCC - Complications:
acute liver failure
portal hypertension
The cause of death is anorexia with tumour cachexia, accompanied by signs of circulatory and renal failure.
Occasionally there is intraperitoneal hemorrhage and a tumour rupture with formation of hemorrhagic ascites
Training Module 5 – Version 1.1
For Internal Use Only
®
Liver Cancer
Primary Liver Cancer
Secondary Liver Cancer
Hepatic neuroendocrine metastasis
Training Module 5 – Version 1.1
For Internal Use Only
®
Secondary Liver Cancer
Many Patients with cancer will develop hepatic metastases
Liver metastases develops via the portal vein, via the hepatic artery or via lymphatic permeation.
In many cases there will be widespread dissemination and liver involvement will not be a separate medical problem
Training Module 5 – Version 1.1
For Internal Use Only
®
Secondary Liver Cancer
If the metastases are widespread the expectation of life is only 2-3 months
Metastatic carcinoid tumours may be very slow growing, and in this disease hepatic metastases are compatible with survival of 3-5 years
Training Module 5 – Version 1.1
For Internal Use Only
®
Secondary Liver Cancer
Blood circulation
Training Module 5 – Version 1.1
For Internal Use Only
®
Secondary Liver Cancer
Most common ‘feeding’ primary tumours
breastlungmelanoma
colorectal
Only portal hepatic metastases have a low probability of extrahepatic disease
Training Module 5 – Version 1.1
For Internal Use Only
®
Secondary Liver Cancer
Hepatic colorectal metastasis
Approximately 160,000 new cases of colorectal cancer (CRC) are diagnosed each year in the United States
Approximately 62,000 deaths are expected due to colorectal cancer (CRC) in 2006 (US)
Training Module 5 – Version 1.1
For Internal Use Only
®
Secondary Liver Cancer
50% of patients in whom the primary tumour drains into the portal vein will develop hepatic metastases!
50
50
Hepatic colorectal metastasis
Training Module 5 – Version 1.1
For Internal Use Only
®
Secondary Liver Cancer
cancer umbilicusmetastases
Training Module 5 – Version 1.1
For Internal Use Only
®
Secondary Liver Cancer
Training Module 5 – Version 1.1
For Internal Use Only
®
Secondary Liver Cancer
Number of nodes / lobes affected
A solitary node is found in some 10% of patients at the time of diagnosis
In 15-20% of cases only one lobe is effected
At the time of diagnosis most patients have multiple nodes in both lobes
Training Module 5 – Version 1.1
For Internal Use Only
®
Secondary Liver Cancer
increasing malaisefeeling of weaknessfebrile attacksupper abdominal painanorexiaweight loss
Symptoms:
But: Metastases are characteristically asymptomatic.
Training Module 5 – Version 1.1
For Internal Use Only
®
Secondary Liver Cancer
hepatomegaly (liver growth)hardening of the liveroccasional palpability of tumour nodesoccasional ascitesoccasional thrombosis of the portal veinoccasional swelling of the lymph nodes
Clinical findings:
Training Module 5 – Version 1.1
For Internal Use Only
®
Secondary Liver Cancer
biochemistry: rise in γ-GT is characteristictumour markerssonographycomputer tomography (CT)MRIexplorative laparoscopyfine needle biopsy (FNB)
Diagnosis:
Training Module 5 – Version 1.1
For Internal Use Only
®
Secondary Liver Cancer
Laboratory findings:
Training Module 5 – Version 1.1
For Internal Use Only
®
Secondary Liver Cancer
Prognosis (CRC-Metastasis):
The natural course of disease shows an average survival rate of 3-10 months
The 5-year survival rate is 2% to 8%
In almost all cases the patients die because of their metastatic liver disease
Training Module 5 – Version 1.1
For Internal Use Only
®
Liver Cancer
Primary Liver Cancer
Secondary Liver Cancer
Hepatic neuroendocrine metastasis
Training Module 5 – Version 1.1
For Internal Use Only
®
Secondary Liver Cancer
Hepatic neuroendocrine metastasis:
Neuroendocrine tumours (NET) are rare tumours arising from cells within the gastrointestinal mucosa and pancreatic islet that normally secret regulatory hormones
Up to 93% of patients with neuroendocrine tumours develop liver metastasis.
A mean survival up to 8.1 years has been reported
Training Module 5 – Version 1.1
For Internal Use Only
®
Liver Cancer
Primary Liver Cancer
Secondary Liver Cancer
Hepatic neuroendocrine metastasis
Training Module 5 – Version 1.1
For Internal Use Only
®
Liver Cancer
What is most important to remember?
HCC – Incidence and Prognosis
CRC – Liver Metastasis
NET
