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Hepatocellular carcinoma final


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HCC, mridul GS

Published in: Health & Medicine
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Hepatocellular carcinoma final

  2. 2. Epidemiology • Hepatocellular carcinoma is the most common primary malignancy of liver worldwide & one of the most common malignancies worldwide (5th ). • Its common in cirrhotics and hepatitis B and hepatitis C virus infection • Male to female ratio: 4:1 • Right lobe is commonly involved • Usually unicentric
  3. 3. AETIOLOGY • Hepatitis -increase risk 100 -200 fold, 75-80% of HCC are positive for HBs Ag. • Hepatitis C • Cirrhosis - 70% of HCC arise on top of cirrhosis • Toxins -Alcohol ,Tobacco ,Aflatoxins ,DDT, Herbicides • Clonarchis sineisis infection • Inherited metabolic diseases Hemochromatosis Alpha-1 antitrypsin deficiency Glycogen storage disease Porphyria cutanea tarda Autoimmune hepatitis • Anabolic steriods , OCP’s
  4. 4. CLINICAL FEATURES • Painless mass (irregular,hard) in right hypochondriac region with loss of weight and apetitie. • Jaundice if present is due to heptic dysfunction, but occasionaly due to compression of bile duct • Ascites , splenomegaly and features of portal hypertension • Hepatic thrill /bruit • Fever may be present due to tumour necrosis
  5. 5. • Gastrointestinal bleeding may be the presentation in 10 % due to portal hypertension • Occasionally may present with paraneoplastic syndromes 1%- • Features of chronic liver diseases- jaundice,dilated veins, palamar erythema, gynecomastia, testicular atrophy.
  6. 6. HISTOLOGY • Well differentiated • Moderately differentiated • Poorly differentiated GROSSLY CLASSIFIED INTO Hanging type Pushing type Infiltrative type
  7. 7. Spread of tumours • Lymphatic spread Lymphatic within liver, to lymph node in porta hepatis, and other abdominal lymph nodes. Blood spread To lung, bone, adrenals Direct infiltration To diaphragm and neighboring structures
  8. 8. Distinct variants of hcc
  9. 9. Fibrolamellar variant of hcc
  10. 10. • No elevation of AFP • Tumor marker is vitamin b12 binding protein • Increase in neurotensin levels • Left lobe commonly involved • Involve lymph node commonly • Fibrous stroma with hyaline band are typical
  11. 11. Investigations 1) AFP produced by 70% of HCC > 400ng/ml PIVKA II increased in 80 percent of patient 2) Imaging USG: focal lesion in the liver of a patient with cirrhosis is highly likely to be HCC,Hyperechoic mass,mosiac pattern with thin halo - Spiral CT of the liver: more reliable and ideal - MRI with contrast enhancement: useful for small hcc.MR angiography is done to see tumor thrombus in portal vein and IVC
  12. 12. Biopsy is rarely required for diagnosis in 1-3 % Biopsy of potentially operable lesions should be avoided where possible • Celiac angiography • Liver function test • Ascetic tap for cytology • Metastatic workup- HRCT chest
  13. 13. Staging of hcc (AJCC)
  14. 14. Treatment(SURGERY) • The only proven potentially curative therapy for HCC • Hepatic resection or liver transplantation • Patients with single small HCC (≤5 cm) or up to three lesions ≤3 cm • Involvement of large vessels (portal vein, Inferior vena cava) doesnt automatically mitigate against a resection; especially in fibrolamellar histology
  15. 15. • Hepatic resection should be considered in HCC and a non-cirrhotic liver (including fibrolamellar variant) • Resection can be carried out in highly selected patients with cirrhosis and well preserved hepatic function (Child-Pugh A) who are unsuitable for liver transplantation. It carries a high risk of postoperative decompensation
  16. 16. • Recurrence rates of 50–60% after 5 years after resection are usual (intrahepatic) • Liver transplantation should be considered in any patient with cirrhosis • Patients with replicating HBV/ HCV had a worse outlook due to recurrence and were previously not considered candidates for transplantation
  17. 17. Treatment (non-Surgical) should only be used where surgical therapy is not possible. 1) Percutaneous ethanol injection (PEI) • has been shown to produce necrosis of small HCC. • It is best suited to peripheral lesions, less than 3 cm in diameter 2) Radiofrequency ablation (RFA) • High frequency ultrasound to generate heat • good alternative ablative therapy • No survival advantage • Useful for tumor control in patients awaiting liver transplant
  18. 18. 3) Cryotherapy • intraoperatively to ablate small solitary tumors outside a planned resection in patients with bilobar disease 4) Chemoembolisation • Concurrent administration of hepatic arterial chemotherapy (doxirubicin) with embolization of hepatic artery • Produce tumour necrosis in 50% of patients • Effective therapy for pain or bleeding from HCC • Affect survival in highly selected patients with good liver reserve • Complications: (pain, fever and hepatic decompensation
  19. 19. 5) Systemic chemotherapy – very limited role in the treatment of HCC with poor esponse rate – Best single agent is doxorubicin (RR: 10- 20%) – Combination chemotherapy didn’t response but survival – should only be offered in the context of clinical trials 6) Hormonal therapy - Nolvadex, stilbestrol and flutamide 7) Interferon-alfa 8) retinoids and adaptive immunotherapy (adjuvant)
  20. 20. THANK YOU