Hepatocellular Carcinoma. Amr Khayat, MBBS. Hepatocellular carcinoma (HCC) is a primary malignancy of the liver. It is now the third leading cause of cancer deaths worldwide, with over 500,000 people affected. Hepatitis and excessive alcohol are the leading causes of HCC.
Amr Khayat, MBBS
Hepatocellular carcinoma (HCC) is a primary malignancy of the liver.
It is now the third leading cause of cancer deaths worldwide, with over 500,000 people affected.
Hepatitis and excessive alcohol are the leading causes of HCC.
(Hepatitis B or hepatitis C, 20%) or with cirrhosis (about 80%).
HCC may present with right upper quadrant pain, weight loss, jaundice, bloating from ascites, and signs of decompensated liver disease.
In patients with lesions less than 1 cm, >>>> conservative management with close follow-up and no biopsy is recommended.
In patients with 1- to 2-cm lesions, a biopsy should be performed,.
Patients with lesions greater than 2 cm, cirrhosis, characteristic imaging studies, and elevated AFP values can be managed without biopsy.
Patients with large tumors who are not candidates for resection or transplantation, >>>>>> biopsy is frequently not indicated.
Llovet JM, Fuster J, Bruix J. The Barcelona approach: diagnosis, staging, and treatment of hepatocellular carcinoma. Liver Transpl. Feb 2004;10(2 Suppl 1):S115-20.
The Child-Pugh score is used to assess the prognosis of chronic liver disease, mainly cirrhosis. To determine treatment required and the necessity of liver transplantation.
The score employs five clinical measures of liver disease. Each measure is scored 1-3, with 3 indicating most severe derangement.
Chronic liver disease is classified into Child-Pugh class A to C, employing the added score from above.
“ Palliative ”
Llovet JM, Fuster J, Bruix J. Intention-to-treat analysis of surgical treatment for early hepatocellular carcinoma: resection versus transplantation. Hepatology 1999; 30: 143440.
Mazzaferro V, Regalia E, Doci R, et al. Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis. N Engl J Med 1996; 334: 6939.
While Waiting :
Adjuvant therapies whilst on the waiting list are used in most centers to prevent tumor progression.
Liovet hepatology 1999
138 pt with cirrhosis and HCC
85 LT and 53 Resection
Child’s A and B
For patients who cannot undergo resection.
Complete responses in more than 80% of tumors smaller than 3 cm in diameter, but in 50% of tumors of 3-5 cm in size.
5-year survival rates of 40%-60%. reported in patients with small single tumors, commonly <2 cm in diameter.
Although these treatments provide good results, they are unable to achieve response rates and outcomes comparable with surgical treatments.
Transarterial Embolization and Chemoembolization is recommended as first line non-curative therapy for non-surgical patients with large/multifocal HCC who do not have vascular invasion or extrahepatic spread.
Sala M, Llovet JM, Vilana R, et al. Initial response to percutaneous ablation predicts survival in patients with hepatocellular carcinoma. Hepatology 2004; 40: 135260.
Lencioni R, Cioni D, Crocetti L, et al. Early-stage hepatocellular carcinoma in patients with cirrhosis: long-term results of percutaneous image-guided radiofrequency ablation. Radiology 2005; 234: 9617.
Omata M, Tateishi R, Yoshida H, Shiina S. Treatment of hepatocellular carcinoma by percutaneous tumor ablation methods: ethanol injection therapy and radiofrequency ablation. Gastroenterology 2004; 127: S15966.
Radiology 1999; 210:655
Lin et al. 2004
RFA : More expensive, more complication, more seeding.
PEI: More Sessions, less effective in tumors 2cm
# Bruix J, Sala M, Llovet JM. Chemoembolization for hepatocellular carcinoma. Gastroenterology 2004; 127: S17988.
# Llovet JM, Real MI, Montana X, et al. Arterial embolisation or chemoembolisation versus symptomatic treatment in patients with unresectable hepatocellular carcinoma: a randomised controlled trial. Lancet 2002; 359: 17349.
# Lo CM, Ngan H, Tso WK, et al. Randomized controlled trial of transarterial lipiodol chemoembolization for unresectable hepatocellular carcinoma. Hepatology 2002; 35: 116471.
Meta-analysis of 7 randomized controlled trials
Palliative not Curative.
Regional (Intra-arterial) better that systemic.
Resistant to many agents.
Bruix J, Sherman M, 2005: Hepatology 42:1208-1236.
Early-stage hepatocellular carcinoma is typically clinically silent, and HCC is often advanced at first manifestation.
Without treatment, the 5-year survival rate is less than 5%.
Complete surgical resection followed by hepatic transplantation offers the best long-term survival, but few patients are eligible for this therapy.
Radiofrequency ablation is the preferred method for managing unresectable small HCCs that are few in number. More widespread disease is treated with percutaneous therapies such as chemoembolization.
Systemic administration of biologic and chemotherapeutic agents is minimally successful in slowing the growth of HCC and typically is used to control symptoms in patients with overwhelming disease.
A multidisciplinary approach that includes surgery, systemic therapy, and radiation therapy and that is based on the cooperation of radiation oncologists, interventional and diagnostic radiologists, hepatologists, and pathologists offer the best chance of a cure or at least a longer and more normal life.