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- Nisha Chand, MD
- Todd Stravitz, MD
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2
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- 64 y/o WM with Dx of Cryptogenic Cx ’02
- Cx complicated by ascites, encephalopathy, jaundice.
- Labs: Plts -84, AST/ALT - 118/121, TB - 3.6, Alb - 2.7, PT - 15.2, AFP
9.1
- U/S 2/02: Negative, CT 2/02: Negative
- Pt was lost to follow up for 1 year
- Represents with ascites and encephalopathy
- AFP: 762
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3
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4
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- Most Common Primary Cancer of Liver
- Incidence: Geographic Region
- Commonly occurs in patients with cirrhosis
- Potentially Curable
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5
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- Incidence and Risk Factors
- Surveillance
- Diagnostic Confirmation / Assessment of Disease Extention
- Prognosis
- Treatment
- Curative Treatments
- Adjuvant / Palliative Therapy
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6
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7
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8
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9
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10
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11
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- Proportion of patients with HCC in the US who have Serologic Evidence of
Chronic Viral Hepatitis
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12
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- Cirrhosis : Irrespective of Etiology
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13
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- Summary of several studies that reported the annual incidence rates of
HCC among patients with HCV-related cirrhosis
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14
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15
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16
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17
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- Repeated application of screening tests over time in order to reduce
disease-specific mortality
- Pts at risk / Eligible for treatment
- Final Result: Increased successful treatment and decreased disease
specific mortality
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18
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- Important health problem
- Accepted treatments are available
- Facilities for diagnosis and treatment are available
- Recognizable in latent/early stage
- Suitable Tests for screening are available
- The screening tests are acceptable to the population
- The natural history of the condition is understood
- Agreed policy on whom to treat is available
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19
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20
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- Common / Easily Used
- Cut-off level of 20 ng/ml: SE
60% SP 90.6%
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21
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- >500 ng/ml : Hep B or C reactivation
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22
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- The PPV and NPV : 25% and 97.7%
- For Pts without hepatitis B or C, PPV = 100%
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23
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24
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- AFP L 3
- Des-gamma-carboxy prothrombin
- PIVKAA II
- GGTII
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25
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- Superior to AFP for detection of HCC
- Good availability
- Low cost
- No radiation
- Good patient acceptance
- Can assess patency of portal vein.
- BUT: User dependent
- Diagnostic efficiency continues to improve (Contrast enhanced / Echo
enhanced)
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- AFP - no use for screening and only useful for confirmation of
diagnosis?
- Bolondi et al: AFP even >200 ng/ml : does not increase detection rate
of HCC in absence of nodules visible w/ US
- Combining US and AFP: Sensitivity 100%???
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- Related to tumor growth rate
- Sheu et al, Gastro 1985: Most rapidly growing HCC take ~4-6 mo to grow
to 3 cm
- Trevisani et al, Am J Gastro ‘02:
- Prevalence Pts fullfilling
Milano Criteria
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30
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- Baseline Costs in Costs in
- costs* screened pts* unscreened pts*
- Surveillance program
- AFP
14 40 236
1 456
- Ultrasonography
47 135
078 4 888
- Resulting cost 175 314 6 344
- Diagnostic tests
- Computed tomography 1 530 11 322 15 912
- Echo guided biopsy
95 5 700 9 025
- Treatments
- PEI 1 610 22 540 32 200
- TACE 3 250 165 750 292 500
- Hepatic resection 11 970 47 880 99 850
- OLT 54 120 324 720 432 960
- Resulting cost 753 226 858 791
- Cost for treatable hepatocellular carcinoma 17 934 14 555
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- Crucial to indicate treatment and achieve optimal outcomes.
- CT and MRI
- Indications for CT / MRI:
- Absolute AFP > 20 ng/ml
- Trend of Increasing AFP
- Lesion seen on US
- Inadequate US
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33
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34
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35
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- Sensitivities < 50% for detection of lesions smaller than 2 cm.
- Recently, the sensitivities and accuracy of MRI have shown improvement
for 1 cm to 2 cm sized nodules.
- Comparison of MRA with Helical CT showed better detection of all
nodules, esp. 1 – 2 cm nodules with MRI
- ( All: 76% vs 61% 1-2 cm: 84% vs 47%)
- Best MRI technology: Contrast-enhanced 3-D MRI with angiographic
sequences
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37
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- No studies yet have defined the best recall policy.
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- Cyto-histological criteria
- Non-invasive criteria (restricted to cirrhotic pts)
- Radiological criteria: two coincident imaging techniques (US, CT, MRI
+ Angio)
- Focal lesion >2 cm with arterial
hypervascularization
- Combined criteria: one imaging technique associated with AFP
- Focal lesion >2 cm with arterial
hypervascularization
- AFP >400 ng/ml
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39
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- Is there evidence of portal venous extension?
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40
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- Child-Pugh
- TNM
- Okuda Staging System
- Cancer of the Liver Italian Program Score (CLIP)
- Barcelona Clinic Liver Cancer Staging
- American Joint Committee on Cancer(AJCC)
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42
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43
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- Liver Transplantation
- Surgical Resection
- Chemoablative Therapy (TACE/TAE)
- Locoregional Ablative Therapy
(Radiofrequency, Microwave, Laser)
- Cryotherapy
- Percutaneous Ethanol Injection
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45
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- 1. Single Tumor < 5 cm
- OR
- Less than 3 tumors, largest being < 3 cm
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46
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47
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48
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49
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50
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- Option for few pts with HCC arising in a normal liver / well preserved
hepatic function.
- Proper selection, 5 year survival can be better than for OLT (70%)
- Segmentectomy / Subsegmentectomy
- Single, small tumor (<5cm)
- Bili <1
- Absence of Severe Portal HTN (<10mmHg)
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52
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- Cha et al. J of the Amer College of Surgeons, Nov 2003:
- Predictors of Recurrence
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53
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54
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- Ischemic necrosis
- Allows hepatic arterial injection of chemotherapeutic agents
- Reduce Systemic Toxicity and Increase Local Effects
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55
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- 97.5% Ethanol – induce coagulative necrosis
- Amount of ethanol correlates with cubic volume of tumor, with 1 cm rim
of normal tissue.
- Small encapsulated tumors with <3 in #
- No damage to remaining parenchyma
- Low Cost, Easy Operation
- Multiple treatment sessions and needle passes
- Painful
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56
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57
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58
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- Rising incidence in the US
- Surveillance: Q 6 mo to 1 year with at least one modality of imaging
- Only good prognostic factor is finding tumor early with small HCC and no
vascular invasion or portal vein thrombosis.
- Great survival benefit in Pts who get transplanted or resection in early
stage
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Notes
