1500 death per year UK, avarage age 66
5 years survival for both resection and transplantation is 50%
Surveillance using abdominal ultrasound and α-fetoprotein (AFP) estimation can detect HCC of a smaller size than those presenting without screening.
5 years survival for both resection and transplantation is 50%
Surveillance using abdominal ultrasound and α-fetoprotein (AFP) estimation can detect HCC of a smaller size than those presenting without screening.
Surveillance for hepatocellular carcinoma should be considered in the following high risk groups:
- Males and females with established cirrhosis due to hepatitis B virus (HBV), particularly those with ongoing viral replication
– Males and females with established cirrhosis due to HCV
– Males and females with established cirrhosis due to genetic haemochromatosis
– Males with alcohol related cirrhosis who are abstinent from alcohol or likely to comply with treatment
– Males with cirrhosis due to primary biliary cirrhosis
If surveillance is offered, it should be six monthly abdominal ultrasound assessments in combination with serum AFP estimation.
Diagnosis of HCC
A focal lesion in the liver of a patient with cirrhosis is highly likely to be HCC.
Initial assessment should be by spiral computed tomography (CT) of the liver (local spread) and thorax (metastases).
Magnetic resonance imaging (MRI) with contrast enhancement or angiography with lipiodol injection and follow up CT may increase the accuracy of detection of other liver lesions.
Biopsy is rarely required for diagnosis, and seeding of tumour in the needle tract occurs in 1–3%. Biopsy of potentially operable lesions should be avoided where possible
Treatment of HCC
The only proven potentially curative therapy for HCC remains surgical, either hepatic resection or liver transplantation, and patients with single small HCC (<5 cm) or up to three lesions <3 cm should be referred for assessment for these treatment modalities.
Milan criteria:
- single HCC less than 5 cm
- up to 3 nodules less than 3 cm
70% 5 years survival, 15% recurrence.
UK guidelines 2008:
- single tumour less than5 cm.
- up to 5 lesion all less than 3 cm.
- Single lesion more than 5 cm and less than 7 cm with no progression.
Milan criteria:
- single HCC less than 5 cm
- up to 3 nodules less than 3 cm
70% 5 years survival, 15% recurrence.
UK guidelines 2008:
- single tumour less than5 cm.
- up to 5 lesion all less than 3 cm.
- Single lesion more than 5 cm and less than 7 cm with no progression.
Liver transplantation should be considered in any patient with cirrhosis and a small (5 cm or less single nodule or up to three lesions of 3 cm or less) HCC
Patients with replicating HBV had a worse outlook due to HBV recurrence and were previously not considered candidates for transplantation.
Effective antiviral therapy is now available and patients with small HCC, as defined above,
should be assessed for transplantation.
Hepatic resection should be considered as primary therapy in any patient with HCC and a non-cirrhotic liver (including fibrolamellar variant).
Resection can be carried out in highly selected patients with hepatic cirrhosis and well preserved hepatic function (Child-Pugh A) who are unsuitable for liver transplantation.
Non-surgical management
Non-surgical therapy should only be used where surgical therapy is not possible.
Locoregional therapies:
- Percutaneous ethanol injection (PEI):
has been shown to produce necrosis of small HCC.
It is best suited to peripheral lesions, less than 3 cm in diameter.
Respose rate > 80% in tumours <3 cm="" p="">
has been shown to produce necrosis of small HCC.
It is best suited to peripheral lesions, less than 3 cm in diameter.
Respose rate > 80% in tumours <3 cm="" p="">
- Radiofrequency ablation(RFA):
may be a good alternative ablative therapy but data are limited.
Better local control but techniqualy difficult and more side effects
may be a good alternative ablative therapy but data are limited.
Better local control but techniqualy difficult and more side effects
- Chemoembolisation :
Can produce tumour necrosis and has been shown to affect survival in highly selected patients with good liver reserve.
Chemoembolisation using lipiodol is effective therapy for pain or bleeding from HCC.
Can produce tumour necrosis and has been shown to affect survival in highly selected patients with good liver reserve.
Chemoembolisation using lipiodol is effective therapy for pain or bleeding from HCC.
-,Systemic chemotherapy with standard agents has a poor response rate and should only be offered in the context of trials of novel agents.
- Hormonal therapy with tamoxifen has shown no survival benefit in controlled trials and is not recommended.
 |
| HCC. Arterial hypervascularity and venous or delayed phase washout |
BSG Guideline here
A 68-year-old female with cirrhosis secondary to nonalcoholic steatohepatitis is found to have a new 2.2 cm mass in the right lobe of the liver during a surveillance ultrasound. Gadolinium contrast MRI is performed and the lesion is found to enhance in the arterial phase and washout in the portal venous and delayed phases. The patient is deemed not to be a candidate for liver transplantation due to co-morbid conditions. She has chronic obstructive pulmonary disease, diabetes and mild renal insufficiency.
ReplyDeleteBlood test results include:
Platelet count 77,000/μL (normal 150-350,000/μL)
AST 45 U/L (normal 0-35 U/L)
ALT 72 U/L (normal 0-35 U/L)
Alkaline phosphatase 105 U/L (normal 36-92 U/L)
Total bilirubin 1.4 mg/dL (normal 0.3-1.3 mg/dL)
Albumin 2.8 g/dL (normal 3.5-5.5 g/dL)
Serum creatinine 1.4 mg/dL (normal 0.7-1.3 mg/dL)
Prothrombin time INR 1.4 (normal 0.8-1.2)
AFP 25 ng/mL (normal <6 ng/mL)
MELD score is 15.
Which of the following is the best option for management of this solitary mass?
A. Transarterial chemoembolization
B. Surgical resection
C. Percutaneous ethanol injection
D. Radiofrequency ablation
E. Sorafenib
Explanation
This patient has a new mass developing in a cirrhotic liver that meets the imaging criteria for a non-invasive diagnosis of hepatocellular carcinoma. With a single tumor less than 5 cm in size she would meet Milan criteria for candidacy for liver transplantation, however she has been deemed not to be a candidate for liver transplantation. The available evidence suggests that the most effective treatments for a small solitary HCC in a patient who is not a candidate for liver transplantation are surgical resection or local ablation. This patient has a calculated MELD score of 15. It has been shown that patients with clinically significant portal hypertension (as evidenced by a platelet count less than 100 x 10(9)/L and a serum bilirubin greater than 1.0 mg/dL) or a MELD score greater than 8 are more likely to develop liver decompensation after major hepatic surgery, consequently, surgical resection is not advisable in this patient. Of the two local ablation methods, radiofrequency ablation and percutaneous ethanol injection, radiofrequency ablation is the more effective therapy. Transarterial chemoembolization is recommended for patients with multifocal hepatocellular carcinoma, while sorafenib is recommended for patients with advanced hepatocellular carcinoma.
D
DeleteSurveillance for hepatocellular carcinoma has been shown to be associated with which of the following?
ReplyDeleteA. Increased detection of early and small tumors
B. Increased eligibility for treatment with local ablation and liver transplant
C. Increased survival
D. A and B
E. A, B, and C
Explanation
At least one randomized controlled trial as well as several cohort and case-control studies have indicated that HCC cases detected by surveillance were more likely to be smaller and at an earlier stage, and more likely to receive potential curative therapy (resection, ablation, liver transplant) than those who present with symptoms outside the surveillance program. Surveillance was associated (including in the randomized controlled trial) with a significant reduction in overall mortality. That trial (n=18,816) compared bi-annual AFP plus US surveillance with no surveillance for five years. Number of patients with HCC was significantly increased in the screened group (OR 1.37; 95% CI 1.00-1.88). Most HCCs in the screened group, but none in the control group, were at an early stage. The survival rate of patients with resected HCC in the screened group reached 52.7% after three and five years, but was 0% for those in the control group.
Surveillance for hepatocellular carcinoma is recommended in at-risk patients:
ReplyDeleteA. Every 6 -12 months
B. Every 2 years
C. Every 3 months
D. Every 3 years
Explanation
Small studies of serial imaging of HCC nodules without treatment indicate that the doubling time of HCC is 3-4 months on average. Based on these findings, a surveillance frequency between 6 and 12 months is generally recommended. The 6-monthly frequency was used in the randomized controlled trial showing efficacy of HCC surveillance.
Which one of the following strategies is recommended for hepatocellular carcinoma (HCC) surveillance in non-obese patients?
ReplyDeleteA. Serum alfa fetoprotein alone
B. Serum alfa fetoprotein combined with ultrasound of the liver
C. Ultrasound of the liver alone
D. Magnetic resonance imaging (MRI)
Explanation
Serum alfa fetoprotein (AFP) at cutoffs of 10-20 ng/ml as a single HCC surveillance test has low sensitivity and specificity and is therefore is no longer a recommended strategy for surveillance. Ultrasound of the liver has modest sensitivity and specificity as a single surveillance test; this is slightly improved by adding serum AFP. The randomized controlled trial that showed the efficacy of surveillance in reducing cancer related, as well as overall mortality employed 6 monthly AFP combined with ultrasound of the liver. MRI may be used for surveillance of HCC; however, due to increased cost, it is currently less ideal than ultrasound for routine surveillance.
B
DeleteSurveillance for hepatocellular carcinoma is indicated in which of the following conditions:
ReplyDeleteA. Autoimmune hepatitis with grade 1 fibrosis
B. Alcoholic hepatitis
C. Hepatitis B infection in a 50-year-old man
D. Hepatitis C with grade 0-1 fibrosis
E. Primary biliary cirrhosis
Explanation
Cirrhosis, irrespective of etiology, is a strong risk factor for HCC (1-5% annual HCC risk). While the risk of HCC in cirrhosis varies by etiology (hemochromatosis, hepatitis C, hepatitis B, autoimmune, primary biliary cirrhosis, and Wilson’s disease, in descending degree of risk), surveillance is recommended in all of these patients. On the other hand, the risk of HCC in HCV-infected patients with mild or no fibrosis is very low. Hepatitis B infection even in the absence of cirrhosis elevates the risk of HCC after age 40 in men and after age 50 in women.
The Milan Criteria for tumor burden of patients with hepatocellular carcinoma are utilized for selection of recipients of deceased donor liver transplantation. Which patient characteristics would allow such a transplantation under the Milan Criteria?
ReplyDeleteA. A single nodule 5 cm or less in diameter or no more than 3 nodules each 3 cm or less in diameter
B. A single nodule < 7.5 cm
C. No more than 3 nodules each less than 5 cm diameter with a total diameter of < 10 cm
D. A single nodule < 7.5 cm diameter or no more than 3 nodules each < 5 cm diameter with a total diameter of < 10 cm
Explanation
In a study of 48 patients with cirrhosis and hepatocellular carcinoma, candidates chosen for liver transplantation had a single tumor of ≤ 5 cm or no more than 3 tumors each 3 cm or less in diameter. Long-term follow-up suggested reduced carcinoma recurrence. In addition, evidence of vascular invasion by the tumor should not be present.
A 23-year-old woman without known liver disease presents with increasing abdominal girth and right upper quadrant abdominal pain. A 10-cm mass is found in the right lobe of the liver. What is histologic evaluation of the mass likely to show?
ReplyDelete1-Hepatocellular carcinoma, fibrolamellar histology
2-Hepatocellular carcinoma, standard histology
3-Lymphoma
4-Metastatic adenocarcinoma
The fibrolamellar variant of hepatocellular carcinoma typically occurs in young patients, has an approximately equal sex distribution, does not secrete alpha fetoprotein, is not caused by chronic HBV or HCV, and almost always arises in a noncirrhotic liver. Fibrolamellar hepatocellular carcinoma is more often amenable to surgical treatment and therefore generally carries a better prognosis than that for conventional hepatocellular carcinoma. It does not, however, respond to chemotherapy any better than do other forms of hepatocellular carcinoma. Chronic ulcerative colitis is a risk factor for primary sclerosing cholangitis, which is, in turn, a risk factor for cholangiocarcinoma. In the Far East, the most common risk factors for cholangiocarcinoma are chronic biliary infections, especially infections with C. sinensis.
A 57-year-old man with Child-Pugh class B cirrhosis due to chronic HCV infection is found to have a 3-cm hepatocellular carcinoma in the right lobe on MRI. There is an enhancing thrombus in the right portal vein. Which of the following is the most appropriate approach to treatment of this patient?
ReplyDelete1-Chemoembolization followed by transplantation
2-Liver transplantation
3-Radiofrequency ablation or ethanol injection
4-Surgical resection
Hepatocellular carcinoma with extension to the portal vein is not considered an indication for liver transplantation given the very high risk of recurrence. Chemoembolization is relatively contraindicated due to portal vein thrombosis. Surgical resection is reserved for hepatocellular carcinoma in patients without cirrhosis. Local ablative therapies would be most appropriate in this case. Sorafenib, an inhibitor of Raf kinase and the receptor tyrosine kinase activity of vascular endothelial growth factor receptors and platelet-derived growth factor receptor is the first of these new agents to be shown to modestly improve survival compared with supportive care. It should be considered for patients with intact hepatic function (Child A) and portal vein thrombosis, extrahepatic disease, or failure of other therapies.
Fibrolamellar hepatocellular carcinoma (FL-HCC) is a rare variant of hepatocellular carcinoma, has distinct pathologic features, and typically occurs in young adults (ages 20 to 40) with no underlying hepatitis or cirrhosis. In addition, the serum levels of alpha-fetoprotein are usually not elevated. Surgery is currently the most effective means of treating and controlling fibrolamellar variant cancer.
ReplyDelete