Post on 02-Jun-2018
8/10/2019 Hepatocellular Carcinoma 3
1/40
LIVER TUMOUR
OLEH :
Dr.HANS MARPAUNG, SpB,FICS
8/10/2019 Hepatocellular Carcinoma 3
2/40
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).
8/10/2019 Hepatocellular Carcinoma 3
3/40
Structure
8/10/2019 Hepatocellular Carcinoma 3
4/40
8/10/2019 Hepatocellular Carcinoma 3
5/40
Tumours in the liver can be benign ormalignant.
Malignant tumours can be primary or,more commonly, secondary ( metastatic).
8/10/2019 Hepatocellular Carcinoma 3
6/40
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.
8/10/2019 Hepatocellular Carcinoma 3
7/40
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)
8/10/2019 Hepatocellular Carcinoma 3
8/40
Stomach2 0%
Breast
2 0%
Colorectal
2 0%
Liver
13%
Lung2 7%
The Global PerspectiveThe Big Five Cancers
8/10/2019 Hepatocellular Carcinoma 3
9/40
The Major Etiological Factors
Chronic hepatitis - types B or C
Cirrhosis/chronic liver disease ofany type
Aflatoxin exposure
Males, increasing age
8/10/2019 Hepatocellular Carcinoma 3
10/40
Cirrhosis
Immature, non-functional cells
8/10/2019 Hepatocellular Carcinoma 3
11/40
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?
8/10/2019 Hepatocellular Carcinoma 3
12/40
8% - High
2-7% - Intermediate
8/10/2019 Hepatocellular Carcinoma 3
13/40
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
8/10/2019 Hepatocellular Carcinoma 3
14/40
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
8/10/2019 Hepatocellular Carcinoma 3
15/40
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
8/10/2019 Hepatocellular Carcinoma 3
16/40
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
8/10/2019 Hepatocellular Carcinoma 3
17/40
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
8/10/2019 Hepatocellular Carcinoma 3
18/40
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.
8/10/2019 Hepatocellular Carcinoma 3
19/40
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
8/10/2019 Hepatocellular Carcinoma 3
20/40
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.
8/10/2019 Hepatocellular Carcinoma 3
21/40
Diagnosis
https://www.aasld.org/
8/10/2019 Hepatocellular Carcinoma 3
22/40
Tumour Detection
8/10/2019 Hepatocellular Carcinoma 3
23/40
8/10/2019 Hepatocellular Carcinoma 3
24/40
8/10/2019 Hepatocellular Carcinoma 3
25/40
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
8/10/2019 Hepatocellular Carcinoma 3
26/40
BCLC(Barcelona-Clinic Liver Cancer staging)
4 levels of staging
- A. Early stage(Child A, single lesion 2)
- D. Terminal stage
8/10/2019 Hepatocellular Carcinoma 3
27/40
BCLC(Barcelona-Clinic Liver Cancer staging)
8/10/2019 Hepatocellular Carcinoma 3
28/40
Initial Management
Patients presenting acutely withdecompensated liver faillure require
specialist hepatological management.Management principles includeattention to nutrition, careful fluid
balance and treatment of portalhypertension
8/10/2019 Hepatocellular Carcinoma 3
29/40
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
8/10/2019 Hepatocellular Carcinoma 3
30/40
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
8/10/2019 Hepatocellular Carcinoma 3
31/40
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)
8/10/2019 Hepatocellular Carcinoma 3
32/40
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~
8/10/2019 Hepatocellular Carcinoma 3
33/40
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
8/10/2019 Hepatocellular Carcinoma 3
34/40
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
8/10/2019 Hepatocellular Carcinoma 3
35/40
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
8/10/2019 Hepatocellular Carcinoma 3
36/40
Liver Transplantation
UNOS( the United Network for Organ Sharing)
* Eligibilitycriteria : a single hepatoma
8/10/2019 Hepatocellular Carcinoma 3
37/40
8/10/2019 Hepatocellular Carcinoma 3
38/40
8/10/2019 Hepatocellular Carcinoma 3
39/40
8/10/2019 Hepatocellular Carcinoma 3
40/40