Said Ooda

Lecturer Of Internal Medicine Medical Research Institute Free Powerpoint Templates 2012

 Cancer liver is the 6th most common cancer, 3rd cause of cancer related death, & accounts for 7% of all cancers. HCC > 90% of primary liver cancer. Each year, HCC is diagnosed in more than half a million people worldwide.
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Adopted from Free England Journal of Medicine 2012 New Powerpoint Templates

 Almost 85% of cases are secondary to hepatitis B &/or C. Worldwide, 54% is due to HBV & 31 % is due to HCV. In Egypt, 40-50% is due to HCV, 25% is due to HBV, & 15% is due to mixed infection. Alcohol intake, smoking, obesity, DM, & NAFLD. Free Powerpoint Templates Aflatoxin exposure.

 Liver cirrhosis whatever the cause (autoimmune hepatitis, steatocirrhosis, hereditary hemochromatosis, alpha1antitrypsin deficiency, and Wilsons disease). One third of cirrhotic patients will develop HCC during their lifetime.
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 Incidence of HCC correlates with severity of cirrhosis & PHTn. Incidence of HCC increases progressively with advancing age, reaches a peak at 70 years. Has a strong male predominance (1 : 2.4).
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Male gender
Long time of infection generally between 15-30 years Positive family history Exposure to aflatoxin, alcohol or tobacco Coinfection with HCV or hepatitis delta virus, High levels of HBV, HBe Ag +ve, Infection with HBV genotype C
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 The estimated risk of HCC is 15 to 20 times as high among persons infected with HCV as it is among those who are not infected. Risk factors include:
Older age. Male sex . Co infection with the human immunodeficiency virus or HBV. And DM, obesity, & Prolonged heavy use of alcohol.
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The rates of HCV in Egypt are among the highest in the world, with a prevalence rate of up to 20%

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 Primary prevention is through HBV vaccine. Secondary prevention is through HBV & HCV treatment. For HBV, data still conflicting are available only with IFN & Lamivudine. For HCV, risk of HCC is reduced among patients achieved SVR. No conclusive evidence in Pts with Free Powerpoint Templates established cirrhosis.

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Surveillance should be performed by experienced personnel by abdominal ultrasound every 6 months

Exceptions:
A shorter follow-up interval (every 3-4 months) is recommended in the following cases:
1-Where a nodule of less than 1 cm has been detected. 2-In the follow-up strategy after resection or loco-regional therapies. Free Powerpoint Templates

 U/S has an acceptable diagnostic accuracy when used as a surveillance test (sensitivity ranging from 58% to 89%; specificity greater than 90%). There are no data to support the use of multidetector CT or dynamic MR imaging for surveillance except for the waiting list for liver transplantation.
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Serological tests that have been investigated for early diagnosis of HCC include :
Alpha-fetoprotein (AFP). Des-gamma-carboxy prothrombin (DCP) also known as Prothrombin induced by Vitamin K Absence II (PIVKAII). The ratio of glycosylated AFP (L3 fraction) to total AFP. Alpha fucosidase.
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BUT
When used as a diagnostic test, AFP levels at a cutoff value of 200 ng/ml has a low sensitivity (22%) with a high specificity. Not elevated in fibrolamellar HCC.

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 Fluctuating levels of AFP in patients with cirrhosis might reflect flares of HBV or HCV infection, exacerbation of underlying liver disease, or HCC development.
Only a small proportion of tumors at an early stage (1020%) present with abnormal AFP serum levels.

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High AFP (200 Vs 400) has been shown to predict poor response to local ablation and locoregional therapy.

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Categories of adult patients in whom surveillance is recommended.

1.
2.

Cirrhotic patients, Child-Pugh stage A and B.

Cirrhotic patients, Child-Pugh stage C awaiting liver transplantation. Non-cirrhotic HBV carriers with hepatitis or family history of HCC. active

3.

4.

Non-cirrhotic patients with chronic hepatitis C Free Powerpoint fibrosis and advanced liverTemplates F3.

Surveillance should be offered to patients with HCV induced advanced fibrosis or cirrhosis, even after achieving SVR.

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The non-invasive diagnosis of 12 cm lesions remains a challenging issue.

A recent prospective study (Hepatology 2011) testing the accuracy of imaging techniques in nodules between 1-2 cm, showed false positive diagnosis (above 10%), mostly due to high grade dysplastic nodules.

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 U/S microbububbles are confined to the intravascular space. Cholangiocarcinoma display homogenous contrast uptake followed by washout, i.e. the vascular pattern assumed to represent HCC.
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Pathologically, the majority of nodules less smaller than 1 cm are not HCC.

But, at the same time dysplastic lesions should be followed by regular imaging studies, since at least one third of them develop a malignant phenotype.
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 HCC radiological hallmark only occurs in a small percentage of patients with 1-2 cm FL.
Delayed diagnosis leads to increased risk of treatment failure or recurrence due to satellites and microvascular invasion which increase obviously beyond in lesions more than 2 cm.
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 Risk of tumor seeding is 2.7% with a median time interval 17 months.

1st biopsy was reported +ve in 60% of cases less than 2 cm, and so, negative biopsy does not rule out malignancy.
Distinct technologies (genome-wide DNA microarray, proteomics, and immunostaining) have been used to identify Free markers Powerpoint Templates of HCC. for early diagnosis

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It is the 1st line treatment option for patients with:

solitary tumors Child A liver Cx

With normal bilirubin With HVPG 10mmHg Free Powerpoint Templates Or platelet count 100.000.

 Only, 5-10% of patients in the west are diagnosed at this very early stage (30% in Japan).

Microscopic vascular invasion involves 20% of tumors of 2 cm in diameter, 30-60% of cases in nodules 2-5 cm, and up to 6090% in nodules above 5 cm in size.
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 Anatomic resection using ultrasound dissector aiming at 2 cm margins provide better outcome. Some surgeons prefer to apply pre-operative PV embolization of the branches supplying the portion of the liver to be resected. In case of recurrence, the patient will be reassessed by BCLC staging.
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 It is the 1st treatment choice for patients with liver dysfunction and have multinodular tumors (3 nodules 3 cm) or those with single tumors 5 cm (Milan criteria). Expanded criteria (single nodule 6.5 cm or 3 nodules 4.5 cm and total tumor size 8cm) have not been recommended yet.
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 Down staging still not recommended. Priority of patients waiting for transplantation is based on MELD score. It is recommended to treat patients waiting for transplant with local ablation, and as a second choice with TACE when waiting times are estimated to exceed 6 months.
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 RFA is considered the standard of care for patients with BCLC 0-A tumors not suitable for surgery.
Ethanol injection is recommended in cases where RFA is technically difficult.

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 It is not recommended to apply RFA as a replacement of resection for patients with early HCC (BCLC A).
Microwave ablation, laser ablation, and cryoablation still not approved.
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 TACE is different from TAE. Patients should be at Child class A or early B (B7) and without ascites. Now, TACE with drug eluting beads is emerging.
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Conformal three dimentional external radiotherapy is considered one of the locoregional therapies for HCC.

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 It is the standard systemic therapy for HCC. Indicated for patients with Liver Cx Child A with advanced tumors (BCLC C) . Also, for those tumors progressing upon locoregional therapies.
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 Use of AFP in follow up is still under investigation. Dynamic CT or MRI are recommended tools to assess response one month after resection, ablation, locoregional, or systemic therapies.
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 Follow up strategy for detection of recurrence include one imaging technique every 3 months during the 1st year, and every 6 months thereafter to complete at least 2 years. Afterwards, regular U/S is recommended every Free Powerpoint Templates 6 months.

Management of Hepatocellular Carcinoma Requires a Multidisciplinary Approach

Hepatobiliary Surgery Hepatology Oncology

Pathology

Radiology

Radiation Free Powerpoint Templates Oncology

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