5 th most common cancer Fastest growing cause of cancer
mortality Risk Factors HBV HCV Cirrhosis Alcoholism Biliary
cirrhosis Hemochromatosis NAFLD Aflatoxins- Esp. in Asian
population 4
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Multifactorial, exact mechanism unclear Inflammation, necrosis,
fibrosis, regeneration of cirrhotic liver Environmental toxins
Mistakes in regenerative pathway Gene mutations: p53, B catenin
Main Theory Repeated necrosis & regeneration + genetic material
in viral hepatitis = mutations & abnormal cell proliferation 5
www.livingwithcancerinternational.com
Chronic Liver Disease: Screen with US every 6 months AASLD
Guidelines Asian men over 40 & Asian woman over 50 Patients
with HBV & Cirrhosis African & North American Blacks
Patients with a family history of HCC US results Nodule < 1 cm
Usually not HCC, monitor every 3 months until they disappear
Nodules > 1 cm Evaluate with CT/MRI Biopsy only if unable to
diagnose on imaging findings Lab Studies Nonspecific: Anemia,
thrombocytopenia, increased LFTs, AFP Raises concern, especially
when over 200 mg/dl 7
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US Small hypo-echoic lesion Heterogenous (fibrosis, fatty
change & calcifications) Hard to distinguish from cirrhosis
8
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CT Focal, multifocal diffuse, infiltrative or atypical
Hypervascularity in arterial phase, washout in portal and delayed
phases Focal necrosis and calcification (10%) Capsule (24%) 9
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10
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MRI T1 Variable Isointense or hyperintense compared to
surrounding liver T2 Variable, typically hyperintense
Post-gadolinium Arterial-phase enhancement +/- discrete feeder
vessels 11
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Unresectable: mortality within 3-6 months Resectable: partial
hepatectomy curative due to regenerative nature of liver 2/3 of the
liver can be resected Role of portal vein embolization prior to
partial hepactectomy IR embolizes the right portal vein,
stimulating hypertrophy of noninvolved lobe & can qualify the
patient for resection or bridging to Tx 5 year survival if
resectable: 37-56% Only 10-20% are completely resectable 12
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Medical Therapy Minimally responsive to chemotherapy Sorafenib
(tyr-kinase inhib) used for advanced cases Mainly Palliative
Lactulose titrated to 2-3 loose stools/day to control
encephalopathy in cirrhosis. Diuretics to control ascites
Antibiotic prophylaxis to prevent SBP Surgical Therapy Liver
transplant Resection Small lesions may be cured under RFA done by
IR 13 http://www.ppdictionary.com/viruses/carcinoma_hepatitis_
b.jpg
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Unresectable tumors Increase survival, improve quality of life,
currently not intended for cure Slows progression and is
palliative. Also used to help patients survive partial hepatectomy
or act as a bridge to transplant. Terminology Transarterial
Chemoembolization: TACE Radiofrequency Ablation: RFA Selective
Internal Radiation Therapy: SIRT Portal Vein Embolization: PVE 14
http://www.anes.ucla.edu/images/news/large/DSC02293.jpg
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Percutaneous transhepatic approach Embolization of portal vein
supplying lobe of liver with the tumor Compensatory hypertrophy of
surviving lobe can qualify patient for resection Patients initially
unresectable due to insufficient remaining normal parenchyma may
qualify Post resection morbidity decreased Serve as a bridge to
transplant 15 Right PVE:
http://radiographics.rsna.org/content/22/5/1063/F13.
expansion.html
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Selective injection of antineoplastic agent with a radiopaque
contrast agent (lipiodol) and embolic agent (gelfoam) Higher dose
of chemotherapy due to decreased systemic exposure Post Procedure
Post Embolization Syndrome Hospital stay of 1-3 days Decreased
energy in the following 2 months Abominal Pain, transaminitis
Follow up CT several weeks later to check for tumor response Repeat
TACE Only 2% of patients have complete response from 1 procedure
Considered non-curative (unlike RFA) Base repeat treatment on tumor
response and hepatic reserve 16
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Destroys tumor using thermal energy from high frequency radio
waves Usually used for small tumors (< 3cm) US guided
percutaneous approach Post Procedure Follow up CT/MRI several weeks
later to check for tumor response. Can also follow AFP 17
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Similar to chemoembolization Uses radioactive microspheres
Radioactive isotope Yttrium (Y-90) incorporated into radioactive
spheres Spheres selectively injected and get lodged in tumor
capillaries and proximal vascular supply Localized brachytherapy
Combined radiation and ischemia results in cell death. Post
Procedure Post embolization syndrome with fatigue, constitutional
symptoms, and abdominal pain Follow up CT/MRI several weeks later
to check tumor response. Can also follow AFP. Return to IR if AFP
remains increased. Monitor for variceal bleeds and assessment of
underlying liver function. 18
http://www.rwjuh.edu/images/cancer/sirt image2.jpg
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TACE Post Embolization Syndrome 60-80% of patients Fatigue,
constitutional symptoms, abdominal pain Symptoms last 3-4 days,
full recovery in 7-10 Liver Failure Dependent on preprocedure liver
function 20% of patients, irreversible in 6% Gastroduoenal
ulceration 3-5% Non target embolization into left gastric SIRT Post
Embolization Syndrome 20-55% Hepatic Dysfunction RFA Complications
are rare but include abscess formation, subcapsular hematoma and
tract seeding If HCC is not treated TNM staging: 5 year survival
55%, 37% and 16% for stage I, II, III respectively Okuda system:
tumor size and degree of cirrhosis 8.3, 2.0 and 0.7 months for
stage I, II, and III respectively 19
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HCC: Relatively poor prognosis including both high morbidity
and mortality Main risk factors are chronic liver disease such as
HBV, HCV, and cirrhosis Patients often present with decompensation
of chronic liver disease Medical management generally palliative,
aimed at reducing liver disease symptoms, chemotherapy is
traditionally ineffective Surgical resection and transplant can be
curative 20
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Screen high risk patients with US, f/u with CT/MRI IR
procedures traditionally palliative for unresectable tumors and
those patients who are not yet candidates for liver transplant
Growing evidence suggesting increased role for IO therapies Smaller
(