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Hepatocellular carcinoma

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Case about HepatoCellular Carcinoma

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Hepatocellular carcinoma

  1. 1. HEPATOCELLULAR CARCINOMA
  2. 2.  Hepatocellular Carcinoma is a primary cancer meaning it originated in the Liver(as opposed to Liver metastases,or secondary Liver Cancers which have spread to Liver from other organs) It is commonly associated with Cirrhosis and Hepatitis.  Male to Female ratio is 4:1 for HCC.
  3. 3. Common Cause: 1.Cirrhosis from any cause 2.Hepatitis B or C chronic infection 3.Ethanol chronic consumption. 4.Aflatoxin B1 or other mycotoxins
  4. 4. Unusual Cause: 1.Primary Biliary Cirrhosis 2.Hemochromatosis 3.Alpha 1 Antitrypsin deficiency 4.Hemochromatosis 5.Wilson’s Disease
  5. 5.  Abdominal Pain  Weight Loss  Weakness  Abdominal Fullness and swelling  Jaundice  Nausea
  6. 6.  Hepatomegaly (50 to 90% of patients)  Ascites(30 to 60%)  Abdominal Bruits  Splenomegaly  Spider Angioma  Obstructive Jaundice  Paraneoplastic Syndromes
  7. 7.  Erythrocytosis  Persistent fever  Hypoglycemia  Hypercalcemia  Hypercholesterolemia
  8. 8. Diagnosis of HCC should be bases on followings:  History & P/E  IMAGING(CT,MRI)  LIVER BIOPSY(For Confirmation)  Elevated Serum AFP(more than 400ng/ml)
  9. 9. In patient with higher suspicion of HCC the best method of diagnosis involves: CT scan of the abdomen using IV Contrast agent and three phase scanning:  Before contrast administration  Immediately after contrast administration  After Delay
  10. 10. Biopsy is not needed if following criteria are met on CT: o Hypervascularity in the arterial phase scans o Washout or deenhancement in the Portal and delayed phase studies o Pseudocapsule and Mosaic Pattern Liver Biopsy is not needed if these criteria are met on CT An alternative to a CT imaging study would be the MRI. MRI's are more expensive and not as available because fewer facilities have MRI machines
  11. 11.  On CT, HCC can have three distinct patterns of growth:  A single large tumor  Multiple tumors  Poorly defined tumor with an infiltrative growth pattern
  12. 12. Hepatocellular Carcinoma may appear grossly as: 1.Unifocal(usually large mass) 2.Multifocal(widely distributed nodules of variable size) 3.Diffusely Infiltrative(Cancer,permeating widely and sometimes involving whole Liver)
  13. 13.  Macroscopically,the tumour usually appears as single mass in the absence of Cirrhosis,or as a single/ multiple nodules in the presence of cirrho- -sis  It takes its blood supply from the hepatic artery and tends to spread by invasion into the portal vein and its radicles.  Lymph node metastases are common but Lung and bone metastases are rare.  Microscopically,the tumour resembles hepatocytes when well differentiated and can be difficult to distinguish from normal Liver.
  14. 14.  The status of the non-tumorous liver:  Underlying cirrhosis.  Non-cirrhotic liver (HBV).  Size and extension of the tumour:  Is it ≤5 cm in size/≤3 lesions ≤ 3 cm ?  Vascular involvement.  General condition of patient, the age and expected life expectancy. 24
  15. 15. MANAGEMENT INDICATION PROGNOSIS Recurrence HEPATIC RESECTION Non Cirrhotic HCC 5 year survival is about 50% 50% recurrence rate at 5 years LIVER TRANSPLANTATION Cirrhotic HCC 5 year survival is about 75% Unfortunate ly Hepatitis B & C may also occur in transplante d Liver PERCUTANEOUSABLATION (ETHANOL) TUMOURS OF 3 cm or small 80% cure rate 50% at 3 years CHEMOEMBOLIZATION Cirrhotic Patients with unresectable HCC and good Liver Functions at 2 years No survival benefit Beyond 4 years
  16. 16.  This Scoring system is used to assess the prognosis of Chronic Liver Disease,mainly Cirrhosis.  It is now used to determine the prognosis as well as required strength of treatment and the neccesity of Liver transplantation. Scoring is done by following methods:
  17. 17. MEASURE 1 POINT 2 POINT 3 POINT TOTAL BILIRUBIN (mg/dL) <2 2 to 3 >3 SERUM ALBUMIN (gm/L) >35 28 to 35 <28 PT/INR <1.7 1.71 to 2.30 >2.3 ASCITES NONE Mild Moderate to Severe HEPATIC ENCEPHALOPATHY NONE Grade I to II Grade III to IV(or refractory)
  18. 18. POINTS CLASS 1 Year survival 2 year survival 5 to 6 A 100% 85% 7 to 9 B 81% 57% 10 to 15 C 45% 35%
  19. 19.  SORAFENIB(multitargeted oral tyrosine kinase inhibitor)  SUNITINIB,DOXORUBICIN,CISPLATIN,FLURO- -URACIL are commonly used chemotherapeutic agents.  Unfortunately HCC is relatively chemotherapy resistant
  20. 20.  BCLC Classification  TNM Classification  OKUDA Classification  CLIP Score for HCC  ECOG performance scale
  21. 21.  Gastrointestinal Bleeding  Liver Failure  Distant Metastases
  22. 22.  www.cancer.net  www.cancer.org  www.aapf.org  www.esmo.org  www.mayoclinic.com  DAVIDSON:Internal Medicine  ROBBINS:Pathology
  23. 23. THANK YOU

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