Hepato cellular carcinoma

Hepatocellular carcinoma: 

Hepatocellular carcinoma

Hepatocellular carcinoma: 

Hepatocellular carcinoma Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver The geographic distribution of HCC is clearly related to the incidence of hepatitis B virus (HBV) infection. Also related to HCV infection. HCC is upto 8 times more common in males than in female

Slide 3: 

75% to 80% of HCC cases are related to HBV or HCV infection Chronic exposure to Aflatoxin , produced by Aspergillus species, a hepatotoxin . Alcohol intake. Hepatic adenoma Inherited metabolic liver diseases, such as hereditary hemochromatosis , a 1 -antitrypsin deficiency, and Wilson's disease Chemicals like DDT, CCL4 and drugs anabolic steroids, griseofulvin etc.

Pathalogy: 

Pathalogy Grossly, the growth patterns of HCC can be: Tumor with a stalk - easily resected without sacrifice of a significant amount of non- neoplastic liver tissue. Pushing type of hcc is well demarcated and often contains a fibrous capsule Infiltrative type of HCC and tends to invade vascular structures even at a small size. Hcc is graded as well, moderately, or poorly differentiated.

CLINICAL FEATURES: 

CLINICAL FEATURES Men 50 to 60 years of age Painless RUQ mass Right upper quadrant abdominal pain and a palpable mass. Nonspecific symptoms of advanced malignancy such as anorexia, nausea, lethargy, and weight loss are common. Obstructive jaundice, hemobilia , or fever of unknown origin.

CLINICAL FEATURES: 

CLINICAL FEATURES Paraneoplastic syndrome, most commonly hypercalcemia , hypoglycemia , and erythrocytosis . Can present as a rupture with the sudden onset of abdominal pain followed by hypovolemic shock secondary to intraperitoneal bleeding.

Investigation: 

Investigation Radiologic investigation In the past, liver radioisotope scans and angiography were common methods of diagnosis, but ultrasound, CT, and MRI have replaced these studies. Ultrasound - screening and early detection of HCC, CT and MRI -definitive diagnosis and treatment planning . Contrast-enhanced CT and MRI protocols aimed at diagnosing HCC take advantage of the hypervascularity of these tumors , and arterial phase images are critical to adequately assess the extent of disease. CT and MRI also evaluate the extent of disease in terms of peritoneal metastases, nodal metastases, and extent of vascular and biliary involvement. Detection of tumor thrombus in the portal venous system.

Investigation: 

Investigation CT angiography- shows Vascularity of the tumor, tumour blush,arterial pattern, portal vein invasion. Angiogram is essential while planning resection. CXR/CT scan Chest to ruleout metastasis to Iung .

Investigation: 

Investigation Tumor marker- AFP level greater than 400IU seen in 3/4 th cases. an adjunctive test in patients with liver masses. useful in monitoring treated patients for recurrence after normalization of levels. False-positive elevations of serum AFP can be seen in inflammatory disorders of the liver, such as chronic active viral hepatitis.

Investigation: 

Investigation Routine blood tests LFT PT HBV and HCV serology

Investigation: 

Investigation Percutaneous needle biopsies of liver lesions suspected of being HCC are only necessary in patients who are being considered for nonoperative therapies. risk of tumor cell spillage (∼1%) and rupture or bleeding.

Staging: 

Staging A number of staging systems for HCC exist, but none has ever been shown to be particularly superior,. The TNM staging system is not routinely used for HCC; it does not accurately predict survival because it does not take liver function into account. The Okuda staging system is an older but simple and effective system that takes into account liver function and tumor -related factors.

Okuda Staging system: 

Okuda Staging system Tumor involving >50% of the liver , Presence of ascites , Albumin less than 3 g/dl, and Bilirubin more than 3 mg/dl. STAGE 1=0 points STAGE 2=1-2 points STAGE 3=3-4 points

Fibrolamellar Hepatocellular Carcinoma (FHCC): 

Fibrolamellar Hepatocellular Carcinoma (FHCC) CHARACTERISTIC HCC FHCC Male-to-female ratio 2:1-8:1 1 : 1 Median age (yr) 55 25 Tumor Invasive Well circumscribed Resectability <25% 50%-75% Cirrhosis 90% 5% α- fetoprotein positive 80% 5% Hepatitis B positive 65% 5%

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Surgical Resection Orthotopic liver transplantation Ablative EtOH injection Acetic acid injection Thermal ablation (cryotherapy, radiofrequency ablation, microwave) Transarterial Embolization Chemoembolization Radiotherapy Combination Transarterial and Ablative External-beam Radiation Therapy Systemic Chemotherapy Hormonal Immunotherapy

TREATMENT: 

TREATMENT Percutaneous ethanol injection (PEI) is a useful technique for ablating small tumors . The tumor is killed by a combination of cellular dehydration, coagulative necrosis, and vascular thrombosis. Most tumors less than 2 cm in size can be ablated with a single application of PEI, but larger tumors may require multiple injections. Percutaneous injection of acetic acid is a technique similar to PEI.

TREATMENT: 

TREATMENT Thermal ablative techniques that freeze or heat tumors to destroy them have become common. Cryotherapy uses a specialized cryoprobe to freeze and tumor and surrounding liver tissue with resulting necrosis. Cryotherapy is usually performed at laparotomy or laparoscopically but has recently been performed with percutaneous techniques. One advantage is that the ice ball formed is easily monitored with ultrasound. Disadvantages include a heat-sink effect, limiting the utility of freezing near major blood vessels and a relatively high complication rate of 8% to 41%.

TREATMENT: 

TREATMENT Radiofrequency ablation (RFA) uses high-frequency alternating current to create heat around an inserted probe, resulting in temperatures greater than 60°C and immediate cell death. Can able to ablate tumors as large as 7 cm. The efficacy of RFA for HCCs larger than 3 to 5 cm is limited. RFA is also limited by the protective effect of blood vessels and does not ablate well in these areas.

TREATMENT: 

TREATMENT Transarterial therapy for HCC is based on the fact that most of the tumor's blood supply is from the hepatic artery. Percutaneous transarterial embolization can induce ischemic necrosis in HCC oils such as lipiodol . chemoembolization to be superior to embolization alone. chemotherapy using 5-fluorouracil (5-FU)-based compounds, cisplatin , and doxorubicin has been is being used.

TREATMENT: 

TREATMENT Systemic chemotherapy with a variety of agents has been ineffective for the treatment of HCC and has a minimal role in the treatment of HCC. Response rates are generally less than 20% and of short duration.

TREATMENT: 

TREATMENT Complete excision of HCC either by partial hepatectomy or by total hepatectomy is the treatment. Advances in surgical technique have allowed the development of limited segmental resections when appropriate, which preserves functional liver and improves early postoperative recovery. Selection of the appropriate patient for resection is critical and must take into account the condition of the liver as well as the extent of disease. Patients with Child's B or C cirrhosis or portal hypertension do not tolerate resection..

TREATMENT: 

TREATMENT The best outcomes are found in patients with single small tumors . Multifocal tumors and major vascular invasion are generally associated with a poor outcome.

Slide 24: 

SEGMENTS COUINAUD, 1957 GOLDSMITH AND WOODBURNE, 1957 BRISBANE, 2000 V-VIII Right hepatectomy Right hepatic lobectomy Right hemi- hepatectomy IV-VIII [†] Right lobectomy Extended right hepatic lobectomy Right trisectionectomy II-IV Left hepatectomy Left hepatic lobectomy Left hemi-hepatectomy II, III Left lobectomy Left lateral segmentectomy Left lateral sectionectomy II, III, IV, V, VIII Extended left hepatectomy Extended left lobectomy Left trisectionectomy

Solid Benign Neoplasms : 

Solid Benign Neoplasms Present in about 10% to 20% of the population. Many benign lesions can be adequately characterized by modern imaging studies such as CT, ultrasound, and MRI, but in unclear cases, serum tumor markers (AFP, CEA) and a search for a primary tumor (in the case of suspected metastases) is carried out.

Solid Benign Neoplasms : 

Solid Benign Neoplasms Ultimately, a resection might be necessary to make a definitive diagnosis. Laparoscopic techniques for assessment, biopsy, and resection have become an important diagnostic technique as well.

Liver Cell(Hepatic) Adenoma : 

Liver Cell(Hepatic) Adenoma Rare benign proliferation of hepatocytes in the context of a normal liver. It is predominantly found in young women (aged 20-40) ,female-to-male ratio -11:1. Associated with oral contraceptive pills (OCPs). HAs are usually singular, multiple rare (if 10 or more adenomas is termed adenomatosis ) .

Liver Cell(Hepatic) Adenoma : 

Liver Cell(Hepatic) Adenoma Histologically , composed of cords of benign hepatocytes containing increased glycogen and fat. Bile ductules and the normal architecture of the liver is not present. Hemorrhage and necrosis are commonly seen. Upper abdominal pain may be related to hemorrhage into the tumor or local compressive symptoms.

Liver Cell(Hepatic) Adenoma : 

Liver Cell(Hepatic) Adenoma Physical exam is usually unrevealing, and tumor markers are normal. Dramatic presentations with free intraperitoneal rupture and bleeding can occur. CT usually demonstrates a well-circumscribed heterogenous mass that shows early enhancement during the arterial phase. MRI scans ideal.

Liver Cell(Hepatic) Adenoma : 

Liver Cell(Hepatic) Adenoma Ultimately, however, resection may be necessary to secure a diagnosis in difficult cases. The two major risks of LCA are rupture (with potentially life-threatening intraperitoneal hemorrhage ) and malignant transformation. Laparotomy and resection of the mass, Margin status is not important.

Focal nodular hyperplasia(FNH): 

Focal nodular hyperplasia(FNH) FNH is the second most common benign tumor of the liver and is predominantly seen in young women. FNH is usually a small (<5 cm) nodular mass arising in a normal liver that involves the right and left lobes equally. The mass is characterized by a central fibrous scar with radiating septa.

Focal nodular hyperplasia(FNH): 

Focal nodular hyperplasia(FNH) Microscopically,contains cords of benign-appearing hepatocytes divided by multiple fibrous septa originating from a central scar. The central scar often contains a large artery that branches out into multiple smaller arteries in a spoke-wheel pattern. Female hormones and OCPs have been implicated.

Focal nodular hyperplasia(FNH): 

Focal nodular hyperplasia(FNH) Contrast-enhanced CT and MRI have become accurate methods of diagnosing FNH. These scans usually demonstrate a homogeneous mass with a central scar that rapidly enhances during the arterial phase of contrast administration. Asymptomatic patients with typical radiologic features do not require treatment.

Hemangioma: 

Hemangioma Hemangioma is the most common benign tumor of the liver. women:men (3:1 ratio) and mean age of about 45 years. Enlargement of hemangiomas are by ectasia rather than neoplasia . They are usually single and less than 5 cm in diameter, and they occur equally in the right and left liver. Lesions greater than 5 cm are arbitrarily called giant hemangiomas .

Hemangioma: 

Hemangioma Involution or thrombosis of hemangiomas can result in dense fibrotic masses that may be difficult to differentiate from malignancy. Microscopically, they are endothelium-lined, blood-filled spaces that are separated by thin, fibrous septa. Most commonly, hemangiomas are asymptomatic and incidentally found on imaging studies.

Hemangioma: 

Hemangioma Large compressive masses or Rapid expansion or acute thrombosis can cause symptoms. Spontaneous rupture of liver hemangiomas is exceedingly rare. Kasabach -Merritt syndrome is thrombocytopenia and consumptive coagulopathy LFTs and tumor markers are usually normal in liver hemangiomas .

Hemangioma: 

Hemangioma CT and MRI are usually sufficient if a typical peripheral nodular enhancement pattern is seen. Labeled red blood cell scans are an accurate test. Percutaneous biopsy of a suspected hemangioma is potentially dangerous and contraindicated.

Hemangioma: 

Hemangioma Rupture, change in size, and development of the Kasabach -Merritt syndrome are indications for resection. The preferred approach to resection is enucleation with inflow control, but anatomic resections may be necessary in some cases. Resection of Large central hemangiomas are associated with significant morbidity.