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HEPATOCELLULAR CARCINOMA

HEPATOCELLULAR CARCINOMA. Monton. HCC in Thailand. Most common cancer in Thai male Incidence 5 x 100,000 / year Male : female = 3-8:1 Age > 40 yr. HCC in Thailand. 60-90% associated with cirrhosis Risk factor HBV 35-85% HCV 18.6% Alcohol ~10% etc. aflatoxin.

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HEPATOCELLULAR CARCINOMA

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  1. HEPATOCELLULAR CARCINOMA Monton

  2. HCC in Thailand • Most common cancer in Thai male • Incidence 5 x 100,000 / year • Male : female = 3-8:1 • Age > 40 yr

  3. HCC in Thailand • 60-90% associated with cirrhosis • Risk factor • HBV 35-85% • HCV 18.6% • Alcohol ~10% • etc. aflatoxin

  4. Multisteps carcinogenesis CIRRHOSIS AFLATOXIN INITIATIONPHASE HBV HBC ALCOHOL PROMOTION PHASE

  5. Cause of death • Hepatic failure 39-45% • GI bleeding 13.8-23.3% • Cancer death 10%

  6. Diagnostic criteriaEASL conference 2000 • Cyto-histological criteria • Non-invasive criteria(cirrhosis) 1.Radiological criteria : 2 imaging - focal mass > 2 cm - 1 imaging show hypervascularization 2.Combined criteria - 1 imaging mass >2cm,hypervascularization - AFP > 400 ng/ml

  7. Staging • No standard staging system • Most system focus on 1.performance status 2.tumor characteristics intrahepatic and extrahepatic 3.liver function • French,CLIP,BCLC,CUPI,TNM

  8. Treatment • Curative • Surgery • Liver transplantation • Percutaneous : PEI,RFA • Palliative • TACE • Hormone • Systemic chemotherapy

  9. Surgery • First choice in non-cirrhotic pt • 5yr survival ~ 50% • High recurrent rate : 50% in 3yr • Suspect undetected micrometastasis • 4,000-10,000 baht

  10. Liver transplantation • Cure underlying cirrhosis • 5yr survival ~ 70% • Milan criteria • 1 mass , < 5 cm • 3 mass , < 3 cm • Less available • Long term immunosuppression • 300,000 – 500,000 Baht

  11. Percutaneous • Alternative in unresectable tumor • No destruction to non-tumor tissue • Can do in cirrhosis • Tumor seeding is problem • PEI : percutaneous ethanol injection • 2,000 baht • RFA : radiofrequency ablation • 40,000 baht

  12. TACE • Transarterial chemoembolization • Palliative treatment • Principle • Cytotoxic agent(doxorubicin/cis) + lipiodol • Embolization • Improvement in 2yr survival • 10,000 – 30,000 baht

  13. Contraindicationof TACE • Decompensated cirrhosis particularly bilirubin > 2 mg/dl • Encephalopathy • Reverse or absent portal flow • Tumor burden > 50% of liver • Renal failure • Active infection

  14. Systemic therapy • Hormonal rx • not improve survival • Systemic chemotherapy • not improve survival compared with best supportive care

  15. Future trends • Antiangiogenic agent • Vascular endothelial growth factor inhibitor • Immunotherapy • Tumor specific effector T-cell • Gene therapy • Intratumoral immunomodulatory cytokine

  16. Problem • Most patients are unresectable • High recurrent rate after surgery • Cannot detect micrometastasis • Early detection of HCC is appropriate

  17. HCC surveilance • Focus on cirrhotic patients • Tumor doubling time ~ 6 mo • Tools are 1. AFP 2. Ultrasonography

  18. AFP • Produced from • Fetal liver cell • Yolk sac • Normal range 10-20 ng/ml • AFP increases in • exacerbation of chronic viral hepatitis (20-250 ng/ml) • Germ cell tumor

  19. AFP cut-off Cut-off sens spec NPV PPV 20 60 89.4 97.7 25.1 200 22.4 99.4 400 17.1 99.4 Trevisani et al,J Hepatol,2001

  20. USG • Sensitivity USG 79.4 CT 87.6 MRI 88.9 Yao et al,J Hepatol,2001

  21. Surviellance & recall strategy USG/AFP q 6mo liver nodule no nodule 1-2cm >2cm <1cm AFP^ AFP- FNAB AFP>400 USG/3mo spiralCT imaging no HCC HCC surveillance/6mo Bruix J et al. J Hepatol,2001

  22. Thank you

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