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1. Presented by:
Dr. Aleena Bhari
Dr.KawshikAhmed
Intern doctors, Surgerydepartment
Enam medical collegeand hospital

2. Anatomy of liver

3. Surgical anatomy
The Couinaud
classification
system divides liver
into 8 independent
functional units
(segements)

4. Contd..
• The segments are numbered 1-8.
• The separation of segments is based on itsown dual vascular
inf low,biliarydrainageand lymphatic drainage.
• In general each segment is wedgeshaped with apexdirected
towards hepatic hilium(porta hepatis)
• Segment 1 is caudate lobe lies posterioraround IVC
• Segment 1-5 makeup left hemiliverand remaining right .
• For liver to remainviable, resection occuralong hepaticveinsand
portal vein in the planes that define boundaries of these
segments.

8. INCIDENCE
⚫28/100000 in SEA
⚫10/100000 in SE
⚫5/100000 IN NE
⚫ Incidence is increasing day bydaydue to -chronic
hepatitis B &C virus infection.
⚫-cirrhosis due toanycause.
⚫Thedisease is morecommon in male(4:1)usually in
middleage group(50years).

9. AETIOLOGICAL FACTORS
COMMON
⚫Viral infection-
HEPATITIS B&/C
⚫External source-
alcohol,aflatoxin.
⚫Cirrhosis from any cause.
⚫Non alcoholic
steatohepatitis(NASH)
⚫Wide spread infection
with liverflukes-
Clonorchis sinensis.
UNCOMMON
• Primary biliary cirrhosis
• Hemachromatosis
• alpha 1Antitrypsin
deficiency
• Wilsondisease

11. Pathogenesis
⚫Theexact pathogenesis is unknown.
⚫Thedisease seems tooccur in stages:
Chronic liver injury > cell death >regeneration>
cellular metabolicdysfunction> release of
inflammatory mediators> increase risk of
transforming mutation of hepatocytes.
• Preneoplastic changes –hepatocytes dysplasia can
be seen.

12. Clinical presentation
Symptoms:
Asymptomatic in early stages,discovered only by
screening (ultrasound and AFP).
 Presents with abdominal mass which produces
discomfort &dragging sensation on exercise.
 Weakness,malaise,abdominal or chest
pain,vomiting,jaundice,haematemesis.
 Anorexia,weightloss –incaseof metastasis.

13. Contd….
Sign:
 Jaundice
 Ascites
 Hepatomegaly
 Periumbilical collateral veins
 Variceal bleeding
 Easy bruising
 Hepaticencephalopathy
 Shock

14. Contd…
Local examination:
 Palpable mass in right upperabdomen which is
hard,irregular,tender/nontender.
 Hepatic bruit

15. SPREAD
Tend tospread by invasion intovasculature
mostly portal vein.
Highly metastasis to lymphnode.
Lung and bone metastasis in terminal cases.

16. Diagnosis:
Diagnosis of HCC is done by :
1. Clinical presentation
2.Investigation
3. Staging

17. 1.Investigation:
 Imaging:
- Ultrasonography
- CT Scan
- MRI
-Angiography
 Liver biposy :
-percutanous aspiration orcore biopsy

18. Images of investigation

19. Contd..
 Tumor markers:
-AFP measurement
-viral marker
 Liverradio isotope scans
 Liver function test:
-serum bilirubin
-AST
-ALT
-ALP
-Prothrombin time
-Serumalbumin

20. Contd..

21. El-Serag HB. N Engl J Med 2011;365:1118-1127
MRI Studies Showing the Effects of Hepatocellular Carcinoma at
Different Stages of the Disease.
A: Very early stage (one lesion 1.7cm), B: early stage (2 lesions 2.4 and 1.2 cm)
•C: Intermediate stage (multiple lesions, Childs B), D: Advanced
•(large mass and ascites)

22. 2.Staging: OKUDA staging system
Clinical parameters cut off value points
Tumor size >50%
<50%
1
0
Ascites Present
absent
1
0
Serum albumin(mg/dl) >3
<3
0
1
Serum total
bilirubin(mg/dl)
<3
>3
0
1

23. Contd..
⚫STAGE 1 =0
⚫STAGE 2=1-2 points
⚫STAGE 3=3-4 points

24. TNM STAGING

25. Patient assesment:
By CHILD-TURCOTTE-PUGH Score
Measurements Score
1 2 3
Encephalopathy None Mild Moderate
Ascites None Slight Moderate
Bilirubin(mg/dl) 1-2 2-3 >3
Albumin(g/dl) >3.5 2.8-3.5 <2.8
Prothrombin time <4 sec 4-6 sec >6 sec

26. Contd..
 STAGE A =5-6 points
 STAGE B =7-9 points
 STAGE C =10-15 points

27. Interpretation:
Points Class 1 year survival 10 year survival
5-6 A 100% 85%
7-9 B 81% 57%
10-15 C 45% 35%

28. Screening for HCC
 Aim: Earlyasymptomaticcurable.
 Methods: AFP (every 6 month) & Ultrasound
 Indications: For patientat risk for HCC:-
-Cirrhosis
-Hepatitis B,C
-Alcohol consumption
-Genetic hemachromatosis
-Autoimmune hepatitis
-Non alcoholic steatohepatitis
-Primary biliarycirrhosis
-Alpha1 antitrypsin deficiency

31. Treatment
A. Surgical approach
B. Non surgical therapy

32. A. Surgical approach
a. Segmental or local resection
b. Lobectomyorpartial hepatectomy
c. Extended lobectomy
d. Livertransplantation

33. Contd..
First 3 for: Livertransplantation
for:
Single tumorwithin
single segment
Child Turcotte Stage A
Tumorsize <5 cm
Multiple tumorsize of
each <3cm
Single tumorsize<5cm
Multiple tumorsizeof
each<3cm
Novascular invasion
Noextrahepatic spread

34. Images of surgical treatment

35. B.Nonsurgical therapy
Majorityof HCC not be amenable tosurgical
resection because of :-
=Advanced stageof thecarcinoma &
=Severity of the underlying liverdisease

36. Contd..
Theoptions are:
Ablative
-Ethanol injection
-Aceticacid injection
-Thermal(cryotherapy,readiotherapy,microwave)
Transarterial
-Embolization
-Chemoembolization
Systemic
-Chemotherapy
-Radiotherapy
-Imunotherapy

37. Radiofrequency ablation

38. Transarterial chemo embolization

39. Prognosis after treatment:
o5 yearsurvival rate:- 30-40% after liver
resection
o5yearsurvival rate:- 75% in liver
transplantation
o2 yearsurvival rate :- 60% in transarterial
chemoembolization

42. Conclusion
In brief ,preventing and treating viral
hepatitis may help to reduce the risk of
developing liver cancer.Childhood hepatitis
vaccination of hepatitis B may reduce risk of
it.Proper nutrition,rest,good habits(avoid
alcohol) and safer practises makes a man
healthy.