HEPATOCELLULAR

CARCINOMAWE CAN CHANGE THE OUTCOME

Background

The incidence of hepatocellular carcinoma (HCC) has

continued to rise in recent years.

This increase has been attributed to alcohol-induced

liver diseases, metabolic syndrome, and the rising

number of hepatitis B and C viral infections.

Treatment options are evolving. With better

understanding of liver anatomy and physiology surgical

treatment emerges as the main curative option

Case Discussion

68 years old male, Diabetic/ hypertensive/ IHD ( on medical

management)

RUQ discomfort - 2-3 months

generalized weakness, fatigue, exertional breathlessness

No addictions, No H/O hepatitis infection.

GPE - pallor ++, BMI-35, otherwise normal, good performance

status

Abdomen examination– unremarkable

Investigations

Hb – 6.6 gm % - transfused 2 PRC’s.

PS –Normocytic hypochromic aneamia

Platelets-3.2 lakhs

INR-1.21

LFT bil-1.2,alb 3.3 OT/PT-56/67

Iron , B12 low

Viral markers negative

Echo, ECG - normal

Investigations

UGI scopy – normal study of stomach

Colonoscopy – small Haemorrhoids. Occasional

uncomplicated left colonic diverticulae +

CT abdomen – for evaluation of bleeding

NON CONTRAST CT

CT : ARTERIAL PHASE

CT: PORTAL VENOUS PHASE

CT: EQUILIBRIUM PHASE

DDs for liver SOL

Can you characterise liver lesions on imaging?

IMAGING OF HEPATOMAS

USG, CT, MRI

ULTRASONOGRAPHY IN HEPATOMA

CT OF HEPATOMA

VALUE OF MRI IN HEPATOMASIDEROTIC NODULE – appears black

Dyplastic nodule:

NO ARTERIAL PHASE ENHANCEMENT

HEPATOMA: ARTERIAL PHASE ENHANCEMENT

Differentiation from other solid liver lesions

Focal Nodular Hyperplasia

HepaticAdenoma

Sub capsular feeding artery

Thin capsule with delayed enhancement.

Hemangioma

Further Evaluation ?

Tumour markers

AFP – 423 IU/dl

DCP/CEA/CA 19 9 - normal

?Biopsy

Decision on curative treatment

Biopsy – to do or not to do!!!!!

Risk of biopsy in liver tumors:

False negative – targetting error

Bleeding

Intrahepatic dissemination

Peritoneal dissemination

When to biopsy??

Resectable lesion – NO BIOPSY

Typical radiological features +/- raised AFP – NO BIOPSY

Atypical radiological features + raised AFP – NO BIOPSY

Atypical radiological features + normal AFP + nonresectable - BIOPSY

How to manage this case ?

Diagnosis conformed by Imaging and AFP

Treatment Options for HCC

Surgical ResectionOpenLaparoscopic

Liver Transplantation

Local Ablative TherapiesRFAPEIMicrowave etc

Regional TherapyTACETheraspheres

Hepatic arterial infusion

Systemic chemotherapyRadiation therapyCyberknife

Multimodality therapy

Treatment of HCC

Performance statusAssociated Medical Diseases

Stage of DiseaseSize /Number of lesions

Extrahepatic diseasePortal vein status

Functional hepatic reserve

Which patients should undergo resection?

What resection and how much to

resect

HCC- Child’s A Cirrhosis

Radiological Assessment?

Virtual Surgery

Volumetry of the Liver to assess for

residual liver or future liver remnant (FLR)

HOW CAN TECHNOLOGY

HELP ?

ADVANCED CT IMAGING TECHNIQUES.

TOTAL LIVER VOLUME: 1256 CC

RESIDUAL LIVER VOLUME: 1256-

440CC = 816CC

PERCENTAGE

RESIDUAL LIVER

VOLUME = 64%

TOTAL LIVER VOLUME: 1256 CC

TUMOR VOLUME = 220 CC

TOTAL FUNCTIONAL LIVER VOLUME = 1256-220:

1036 CC

RESIDUAL LIVER VOLUME: 1036-440 = 596 CC.

PERCENTAGE RESIDUAL

LIVER VOLUME =

596 / 1036 : 57%

Assessment

Patient – Good performance status, fit for surgery; medical

factors well controlled

Disease related – Localised disease; no evidence of spread

Liver Status –rt Posterior sectionectomy, Segment 6,7; Good

residual volume

Facilities – Intraoperative USG; Dissecting tools – Waterjet;

Hemostatic tools – harmonic and Aquamantys

Surgeon and team

Armamentarium

Right post sectionectomy for this

patient

Post operative Course

No major morbidity

Discharged on Day 6

Follow up- doing well

FNAC OR BIOPSY FOR DIAGNOSIS?

Malignant tumours of liver can be confidently

diagnosed on FNAC. However, FNAC has limitations

and diagnostic challenges in benign lesions and well-

differentiated HCC.

Biopsy allows architectural, cellular and

immunohistochemical evaluation.

A combined approach of biopsy with clinical findings,

tumour markers and ancillary techniques is preferred.

Microscopy

MICROACINAR PATTERN

HYALINE GLOBULES WITH POORLY

DIFFERENTIATED CELLS

Results of Biopsy in Suspected HCC

Sensitivity of FNA 67-100%

Specificity of FNA 80-100%

Risk of needle track seeding 2.7% overall, 0.9%/year

Median time for seeding: 17/12 (3-48/12)

Silva MA et al.Gut 2008;57:1592-1596

Pathology of HCC

Histopathology of this patient

Prognostic factors

Histology of HCC

Well-differentiated HCCs are those where the tumour

cells closely resemble hepatocytes.

Poorly differentiated HCC are those where the

hepatocellular nature of the tumour is not

very evident from the morphology.

CORE DATA ITEMS IN PATHOLOGY REPORT

Size

Number

Grade

Vascular invasion

Capsular invasion

Resection margin

Type (fibrolamellar variant better prognosis)

Background liver

Lymph node status

Outcome of Surgery

Good risk patient(Non Cirrhotic, Child A CLD)

Disease Status

Surgical expertise

Strict intra op measures – monitoring, less blood loss

Good residual liver volume

Complete resection with good margin

Favourable pathology

Take home messages

HCC - increasing diagnosis due to awareness

Should be evaluated by an experienced team –to select

the best treatment option for increased chance of cure

Do not needle all liver lesions!

Age and size of tumour really do not necessarily rule out

curative surgery

A meticulously planned surgery with intraoperative and

perioperative care results in excellent outcome

Treatment should be undertaken at center’s with

experience and facilities

THANK YOU