3. Background
The incidence of hepatocellular carcinoma (HCC) has
continued to rise in recent years.
This increase has been attributed to alcohol-induced
liver diseases, metabolic syndrome, and the rising
number of hepatitis B and C viral infections.
Treatment options are evolving. With better
understanding of liver anatomy and physiology surgical
treatment emerges as the main curative option
4. Case Discussion
68 years old male, Diabetic/ hypertensive/ IHD ( on medical
management)
RUQ discomfort - 2-3 months
generalized weakness, fatigue, exertional breathlessness
No addictions, No H/O hepatitis infection.
GPE - pallor ++, BMI-35, otherwise normal, good performance
status
Abdomen examination– unremarkable
6. Investigations
UGI scopy – normal study of stomach
Colonoscopy – small Haemorrhoids. Occasional
uncomplicated left colonic diverticulae +
CT abdomen – for evaluation of bleeding
20. Further Evaluation ?
Tumour markers
AFP – 423 IU/dl
DCP/CEA/CA 19 9 - normal
?Biopsy
Decision on curative treatment
21. Biopsy – to do or not to do!!!!!
Risk of biopsy in liver tumors:
False negative – targetting error
Bleeding
Intrahepatic dissemination
Peritoneal dissemination
When to biopsy??
Resectable lesion – NO BIOPSY
Typical radiological features +/- raised AFP – NO BIOPSY
Atypical radiological features + raised AFP – NO BIOPSY
Atypical radiological features + normal AFP + nonresectable - BIOPSY
22. How to manage this case ?
Diagnosis conformed by Imaging and AFP
25. Which patients should undergo resection?
Performance status
Associated Medical Diseases
Stage of Disease
Size /Number of lesions
Extrahepatic disease
Portal vein status
Functional hepatic reserve
34. TOTAL LIVER VOLUME: 1256 CC
RESIDUAL LIVER VOLUME: 1256-
440CC = 816CC
PERCENTAGE
RESIDUAL LIVER
VOLUME = 64%
35. TOTAL LIVER VOLUME: 1256 CC
TUMOR VOLUME = 220 CC
TOTAL FUNCTIONAL LIVER VOLUME = 1256-220:
1036 CC
RESIDUAL LIVER VOLUME: 1036-440 = 596 CC.
PERCENTAGE RESIDUAL
LIVER VOLUME =
596 / 1036 : 57%
36. Assessment
Patient – Good performance status, fit for surgery; medical
factors well controlled
Disease related – Localised disease; no evidence of spread
Liver Status –rt Posterior sectionectomy, Segment 6,7; Good
residual volume
Facilities – Intraoperative USG; Dissecting tools – Waterjet;
Hemostatic tools – harmonic and Aquamantys
Surgeon and team
40. Post operative Course
No major morbidity
Discharged on Day 6
Follow up- doing well
41. FNAC OR BIOPSY FOR DIAGNOSIS?
Malignant tumours of liver can be confidently
diagnosed on FNAC. However, FNAC has limitations
and diagnostic challenges in benign lesions and well-differentiated
HCC.
Biopsy allows architectural, cellular and
immunohistochemical evaluation.
A combined approach of biopsy with clinical findings,
tumour markers and ancillary techniques is preferred.
43. Results of Biopsy in Suspected HCC
Sensitivity of FNA 67-100%
Specificity of FNA 80-100%
Risk of needle track seeding 2.7% overall, 0.9%/year
Median time for seeding: 17/12 (3-48/12)
Silva MA et al.Gut 2008;57:1592-1596
44. Pathology of HCC
Histopathology of this patient
Prognostic factors
45. Histology of HCC
Well-differentiated HCCs are those where the tumour
cells closely resemble hepatocytes.
Poorly differentiated HCC are those where the
hepatocellular nature of the tumour is not
very evident from the morphology.
46. CORE DATA ITEMS IN PATHOLOGY REPORT
Size
Number
Grade
Vascular invasion
Capsular invasion
Resection margin
Type (fibrolamellar variant better prognosis)
Background liver
Lymph node status
47. Outcome of Surgery
Good risk patient(Non Cirrhotic, Child A CLD)
Disease Status
Surgical expertise
Strict intra op measures – monitoring, less blood loss
Good residual liver volume
Complete resection with good margin
Favourable pathology
48. Take home messages
HCC - increasing diagnosis due to awareness
Should be evaluated by an experienced team –to select
the best treatment option for increased chance of cure
Do not needle all liver lesions!
Age and size of tumour really do not necessarily rule out
curative surgery
A meticulously planned surgery with intraoperative and
perioperative care results in excellent outcome
Treatment should be undertaken at center’s with
experience and facilities