Kinds of Liver Cancers diagnosis and Treatements

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Wockhardt Hospitals has proved its medical one-upmanship yet again by successfully performing a major liver re-resection on a 58 year old man. In a case of a recurrent cancerous liver tumor which many hospitals worldwide would shirk from taking up for a second surgery, the expert team at Wockhardt Hospitals led by Dr S K Mathur took the challenge and skillfully excised the tumors in an arduous 11- hour surgical procedure

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Kinds of Liver Cancers diagnosis and Treatements

  1. 1. Liver: An Enigma By Dr. S K Mathur MS, FACS Sr. Consultant GI Surgeon HPB Surgery & Liver Transplantation, Wockhardt hospitals, Mumbai Past President : Indian Chapter of International HPB Association Indian Association
  2. 2. Liver <ul><li>Unique </li></ul><ul><li>Functionally Complex </li></ul><ul><li>Enigmatic </li></ul><ul><li>Resectable </li></ul><ul><li>Transplantable </li></ul>
  3. 3. Liver: An Enigma <ul><li>Liver is the largest organ in the body: wt 1.2-1.5 Kg </li></ul><ul><li>Liver is the most complex organ in the body </li></ul><ul><li>From ancient times liver is considered the “organ of fate” </li></ul><ul><li>Egyptians considered the liver to be the “seat of the life force” </li></ul>
  4. 4. Liver: a Unique organ <ul><li>Anatomy: </li></ul><ul><li>- Dual blood supply </li></ul><ul><li>* Portal Vein </li></ul><ul><li>* Hepatic artery </li></ul><ul><li>HA supplies 35% of blood flow </li></ul><ul><li>Segmental anatomy </li></ul>
  5. 5. Prediction of Hepatic Insufficiency Hepatic Volumetry Normal Liver : Segments Volume 5 + 8 30 % 6 + 7 35 % 1 + 4 20 % 2 + 3 15 % 65 % of Right Liver 35 % of Left Liver (Stone et al Am J Surg 1969)
  6. 6. Liver : Uniqueness It has large functional reserve <ul><li>For survival: 35% of functional liver </li></ul>
  7. 7. Liver : Uniqueness Capacity for Regeneration In 6 weeks liver regenerates to 90% of its original volume
  8. 8. In Greek mythology, Prometheus (Ancient Greek:&quot;forethought&quot;)[1] is a Titan known for his wily intelligence, who stole fire from Zeus and gave it to mortals for their use.[2] Zeus then punished him for his crime by having him bound to a rock while an eagle ate his liver every day only to have it grow back to be eaten again the next day.
  9. 9. Liver: an enigma to Clinicians <ul><li>Liver Tumors </li></ul><ul><li>Parenchymal Liver Diseases </li></ul><ul><li>Cirrhosis </li></ul><ul><li>Liver cell failure Death </li></ul>
  10. 10. Liver Tumors <ul><li>Benign </li></ul><ul><li>- FNH </li></ul><ul><li>- Adenoma </li></ul><ul><li>- Hemangioma </li></ul><ul><li>Cystic </li></ul><ul><li>- Congenital </li></ul><ul><li>- Hydatid </li></ul><ul><li>- Cyst adenoma </li></ul><ul><li>Infective: </li></ul><ul><li>- Tuberculoma </li></ul><ul><li>Malignant </li></ul><ul><li>Primary: </li></ul><ul><li>- HCC </li></ul><ul><li>- hepatoblastoma </li></ul><ul><li>- cystadenocarcinoma </li></ul><ul><li>- Neuroendocrine </li></ul><ul><li>- Lymphoma </li></ul><ul><li>Metastasis: </li></ul><ul><li>- Colo-rectal </li></ul><ul><li>- Neuroendocrine </li></ul>
  11. 11. Liver Cancer (Hepatocellular Carcinoma)
  12. 12. Hepatocellular Carcinoma <ul><li>80 % of all liver tumors </li></ul><ul><li>Male : Female = 3 : 1 </li></ul><ul><li>HCC Underlying chronic liver </li></ul><ul><li>disease (Cirrhosis : 80-90%) </li></ul><ul><li>Normal Liver </li></ul><ul><li>Tumour doubling time : </li></ul><ul><li>median 4-5 months (<5cm) </li></ul>
  13. 13. Hepatocellular Carcinoma <ul><li>Prevalence: </li></ul><ul><li>* Annual incidence of 1 Million new cases </li></ul><ul><li>* Geographical distribution parallels </li></ul><ul><li>The incidence of HBV infection </li></ul><ul><li>High Incidence areas: </li></ul><ul><li>South-east Asia: 10-20 per 100,000 population </li></ul><ul><li>Intermediate Incidence: </li></ul><ul><li>Japan, Middle-east, Mediterranean </li></ul><ul><li>Low Incidence: India, South Africa </li></ul><ul><li>Lowest Incidence: 1-3 per 100,000 population </li></ul><ul><li>Australia, USA, Europe </li></ul>
  14. 14. Hepatocellular Carcinoma <ul><li>Prevalence: </li></ul><ul><li>* Annual incidence of 1 Million new cases </li></ul>
  15. 15. Digestive cancers at TMH 1994-95 Site 1994 1995 All GI 2277 2347 Esophagus 902 921 Large bowel 617 666 Stomach 359 341 Gall bladder 161 167 Pancreas 1 12 134 Liver 88 88 Others 28 30
  16. 16. Hepatocellular Carcinoma <ul><li>Chronic Viral Hepatitis: </li></ul><ul><li>Hepatitis B virus: 80 % of all HCC have HBs Ag +ve </li></ul><ul><li>Relative risk : 200 fold greater than non-infected </li></ul><ul><li>- Duration of Chronic HBs Ag carriers and risk of HCC: </li></ul><ul><li>Strong correlation </li></ul><ul><li>Childhood infection : risk of HCC 40% </li></ul><ul><li>Adults: risk of HCC 10% </li></ul><ul><li>Hepatitis C virus: - In Japan, Spain, and Italy </li></ul><ul><li>80% of all HCC are +ve for Anti HCV </li></ul>Etiology :
  17. 17. Hepatocellular Carcinoma <ul><li>Cirrhosis of liver: due to- </li></ul><ul><li>Chronic Alcohol abuse </li></ul><ul><li>Non-alcoholic Fatty Liver Disease (NASH) </li></ul><ul><li>Other Causes: </li></ul><ul><li>- Budd - Chiari syndrome </li></ul><ul><li>-  1 antitrypsin deficiency </li></ul><ul><li>- Haemochromatosis </li></ul><ul><li>Aflotoxins : </li></ul><ul><li>Toxins of Aspergillus flavus & parasiticus </li></ul><ul><li>(B1,B2 & G1,G2) </li></ul><ul><li>Food products: e.g. peanuts & grains </li></ul>Etiology :
  18. 18. <ul><li>Synthetic heaptocarcinogens : </li></ul><ul><li>- Azo dyes, aromatic amines, </li></ul><ul><li>- pesticides, chlorinated hydrocarbons </li></ul><ul><li>Miscellaneous : </li></ul><ul><li>- Oral contraceptives </li></ul><ul><li>- Anabolic steroids </li></ul><ul><li>- Radiation </li></ul><ul><li>- Thorotrast </li></ul>Hepatocellular Carcinoma Etiology :
  19. 19. Hepatocellular Carcinoma Clinical Presentations <ul><li>Delayed: - Absence of Specific Symptoms </li></ul><ul><li>- Non-palpable liver </li></ul><ul><li>- Large Functional hepatic reserve </li></ul><ul><li>Anorexia & Weight loss </li></ul><ul><li>Fever </li></ul><ul><li>Pain in abdomen: Rupture & bleed: </li></ul><ul><li>Localised: D/D Acute MI </li></ul><ul><li>G.I. bleed: - Variceal due to acute PV Thrombosis </li></ul><ul><li>- Hemobilia </li></ul><ul><li>Obstructive Jaundice </li></ul>
  20. 20. Hepatocellular Carcinoma Diagnosis : Tumour Markers: - - AFP > 400 ng/ml - DCP (des - y - carboxy prothrombin) - CEA
  21. 21. <ul><li>USG </li></ul><ul><li>CT : Contrast enhanced CT - 70 % </li></ul><ul><li>Biphasic Helical CT (PV : tumour v/s bland thrombus) </li></ul><ul><li>a) Arterial phase - Hyperdense </li></ul><ul><li>b) Portal venous phase - Hypo or isodense </li></ul><ul><li>c) Delayed peripheral enhancement – capsulation </li></ul><ul><li>CT angiography </li></ul><ul><li>Lipiodol CT </li></ul><ul><li>MRI - Dynamic bolus gadolinium injection </li></ul><ul><li>(diagnostic accuracy > CT) </li></ul><ul><li>Hepatic Angiography </li></ul><ul><li>PET Scan </li></ul>For small HCC (3mm) Imaging Modalities:
  22. 22. Hepatocellular Carcinoma <ul><li>Treatment Options: </li></ul><ul><li>Surgical </li></ul><ul><li>Non-Surgical </li></ul>
  23. 23. Hepatocellular Carcinoma <ul><li>Non surgical therapies </li></ul><ul><li>Systemic chemotherapy </li></ul><ul><li>Intra-arterial chemotherapy (TAC) </li></ul><ul><li>Trans arterial embolisation (TAE) </li></ul><ul><li>Trans Arterial chemo-embolisation (TACE) </li></ul><ul><li>Trans arterial Radio-embolisation: I 131 or Y 90 </li></ul>
  24. 24. <ul><li>Local Ablation Therapies: </li></ul><ul><li>Intra-tumoural ethanol injection </li></ul><ul><li>Radio frequency ablation </li></ul><ul><li>Cryoablation </li></ul>Non surgical therapies
  25. 25. <ul><li>Surgical Therapies </li></ul><ul><li>Liver Resection </li></ul><ul><li>Liver Transplantation </li></ul>
  26. 26. SURGERY- ANTERIOR TRANSHEPATIC RESECTION Weight 2 .5Kg
  27. 27. Management of HCC <ul><li>Surgical resection : best therapy </li></ul><ul><li>Survival - 3yrs : 68 – 76% </li></ul><ul><li>- 5yrs : 51 – 68% </li></ul><ul><li>*Resection rates : 9 – 37% </li></ul><ul><li>(Ref: SCNA 2004, Ann Surg 2002) </li></ul><ul><li>Liver Transplantation : </li></ul><ul><li>Cures underlying liver disease </li></ul><ul><li>Survival : 5yrs : 50 – 60% (71 – 78%) </li></ul><ul><li>Selection criteria : T1 & T2 lesions </li></ul><ul><li>Problem : Donor shortage </li></ul><ul><li>( Ref: Am J Surg 2002, Arch Surg 2001, Hepatology 2001) </li></ul>
  28. 28. Management of HCC <ul><li>Recurrence of Liver tumor after resection: </li></ul><ul><li>Incidence: 30% </li></ul><ul><li>What are the treatment options? </li></ul><ul><li>Repeat Surgery </li></ul><ul><li>( Re-resection of Liver) </li></ul><ul><li>Or </li></ul><ul><li>Non- surgical therapies </li></ul>
  29. 29. Story of a patient with recurrent liver cancer Agony to Smile
  30. 30. HISTORY <ul><li>58 year old male </li></ul><ul><li>October 2006: Diagnosed to have a tumor in his liver on USG </li></ul><ul><li>CT Scan Confirmed the tumor to be single and localised in his right half of the liver </li></ul><ul><li>CT guided biopsy reported as: </li></ul><ul><li>well differentiated Hepatocellular Carcinoma </li></ul><ul><li>Tumor Marker : AFP was normal </li></ul>
  31. 31. Story of a patient with recurrent liver cancer <ul><li>October 2006: </li></ul><ul><li>Evaluated at a Cancer hospital </li></ul><ul><li>No Co –morbid diseases </li></ul><ul><li>No spread of tumor out side liver </li></ul><ul><li>He underwent Liver resection for his tumor </li></ul>
  32. 32. <ul><li>Was asymptomatic 2 ½ years post surgery. </li></ul><ul><li>In April 2009 : during a follow up USG at the previous hospital </li></ul><ul><li>detected to have recurrence of his tumor at the cut margin of the liver </li></ul><ul><li>CT Scan confirmed the recurrence of the tumor : Three tumors close to each other </li></ul>
  33. 33. <ul><li>Deemed not suitable for re surgery i.e. re-resection of the liver tumor: </li></ul><ul><li>Resurgery on liver is considered hazardous due to adhesions to surrounding organs: </li></ul><ul><li>e.g. Diaphragm, colon, duodenum </li></ul><ul><li>One tumor nodule was close to & extending behind the IVC </li></ul>
  34. 34. IVC Tumors Tumor Liver
  35. 35. Advised Palliative Treatment: Underwent two cycles of TACE in April and June 2009 One tumor nodule which was flush with the IVC could not be embolised
  36. 36. Management of HCC <ul><li>Recurrence of Liver tumor after resection: </li></ul><ul><li>Incidence: 30% </li></ul><ul><li>What are the treatment options? </li></ul><ul><li>Repeat Surgery </li></ul><ul><li>( Re-resection of Liver) </li></ul><ul><li>Or </li></ul><ul><li>Non- surgical therapies </li></ul>
  37. 37. Selection Criteria for Repeat Hepatectomy in Patients With Recurrent Hepatocellular Carcinoma Masami Minagawa, MD,* Masatoshi Makuuchi, MD,* Tadatoshi Takayama, MD,† and Norihiro Kokudo, MD* Ann Surg. 2003 <ul><li>The most widely used treatment of intrahepatic recurrence is transarterial chemoembolization (TACE). </li></ul><ul><li>The 5-year survival rate has ranged from 0% to 27% in patients with postresectional recurrence, even with repeated TACE. </li></ul><ul><li>It is questionable whether this procedure actually enhances survival in such cases. </li></ul>
  38. 38. Selection Criteria for Repeat Hepatectomy in Patients With Recurrent Hepatocellular Carcinoma Masami Minagawa, MD,* Masatoshi Makuuchi, MD,* Tadatoshi Takayama, MD,† and Norihiro Kokudo, MD* Ann Surg. 2003 <ul><li>Repeat resection for recurrent HCC has been reported to be a highly effective treatment in selected patients. </li></ul><ul><li>The 5-year survival rate after repeat resection has been reported to be from 37% to 70%. </li></ul>
  39. 39. <ul><li>Repeat resection for recurrent HCC in selected patients:- </li></ul><ul><li>hepatic resection is the treatment of choice for patients </li></ul><ul><li>who have previously undergone resection of a single HCC at the primary resection </li></ul><ul><li>in whom recurrence developed after a disease-free interval of 1 year or more </li></ul><ul><li>the recurrent tumor had no portal invasion. </li></ul>
  40. 40. Story of a patient with recurrent liver cancer <ul><li>August 2009:Came for 2 nd opinion: </li></ul><ul><li>Evaluation at Wockhardt Hospitals: </li></ul><ul><ul><li>Patient is well built and nourished </li></ul></ul><ul><ul><li>No comorbid illness </li></ul></ul><ul><ul><li>No spread of tumor out side the liver </li></ul></ul><ul><ul><li>Remaining liver normal </li></ul></ul><ul><ul><li>Treatment Offered: Re-resection of the liver </li></ul></ul>
  41. 41. CT Scan
  42. 42. Sectorectomy
  43. 43. Right hepatectomy
  44. 44. Story of a patient with recurrent liver cancer Video
  45. 45. <ul><li>Postoperative course was uneventful </li></ul><ul><li>Out of ICU on Day 2 </li></ul><ul><li>Discharged from the hospital on Day 6 </li></ul><ul><li>Histopathology reported as necrotic tumor at the previous resection site </li></ul><ul><li>Viable tumor adjacent to the stump of the RHV and IVC </li></ul>
  46. 46. Dealing with Cancer and Terrorism <ul><li>Prevention </li></ul><ul><li>Early detection </li></ul><ul><li>and effective damage control </li></ul>
  47. 47. Hepatocellular Carcinoma <ul><li>Prevention </li></ul><ul><ul><li>HBV infection: Vaccination programme </li></ul></ul><ul><ul><li>HCV: Safe Blood bank Practices </li></ul></ul><ul><ul><li>Alcoholism : Awareness & Control </li></ul></ul><ul><ul><li>Obesity Control: Life style Modification </li></ul></ul><ul><ul><li>Aflotoxins : awareness </li></ul></ul>Conclusions
  48. 48. <ul><li>Screening X </li></ul><ul><li>Surveillance Yes </li></ul><ul><li>Diagnosed cases of Cirrhosis </li></ul><ul><li>Programme: </li></ul><ul><li>- AFP every 3 month </li></ul><ul><li>- USG every 3-6 months </li></ul><ul><li>Any suspicious new lesion : CECT </li></ul>Early Detection Screening or Survilliance
  49. 49. <ul><li>Resection is the best treatment </li></ul><ul><li>Assessment for resection by a Liver Surgeon </li></ul><ul><li>Unresectable: due to Anatomical factors </li></ul><ul><li>- Chemo-embolisation +/- RFA: to shrink </li></ul><ul><li>- Portal vein Embolisation: </li></ul><ul><li>Induce hypertrophy of Normal liver </li></ul><ul><li>Re-asses for Resection </li></ul><ul><li>Unresectable due to Advanced liver disease: </li></ul><ul><li>Evaluate for Liver Transplantation </li></ul>Appropriate Management
  50. 50. <ul><li>Unresectable & Non-Transplant Candidates </li></ul><ul><li>- No evidence of Metastasis </li></ul><ul><li>Consider Palliation: </li></ul><ul><li>- PEI </li></ul><ul><li>- RF Ablation </li></ul><ul><li>- TACE </li></ul><ul><li>- Trans arterial radio-embolisation </li></ul><ul><li>Long-acting Octeriotide: Selected patients </li></ul>Appropriate Management
  51. 51. THANK YOU

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