This document discusses hepatocellular carcinoma (HCC). It outlines the main risk factors for HCC as hepatitis B and C, alcohol, aflatoxin, and certain genetic conditions. It notes that 60-80% of HCC cases occur in patients with cirrhosis. The document discusses screening and diagnosis of HCC using AFP levels and imaging modalities. It covers staging of HCC and describes treatment options including surgery, ablation, embolization, and transplantation.
Hepatocellular carcinoma (HCC) is a major cause of cancer mortality worldwide, with over 800,000 deaths annually. Risk factors include chronic hepatitis B and C infection, cirrhosis, and aflatoxin exposure. HCC commonly presents between ages 40-70 and is more common in men. Diagnosis involves imaging such as ultrasound, CT, or MRI showing typical arterial enhancement and washout. Serum markers AFP and DCP are also used. Surveillance is recommended for high risk groups like cirrhotic patients. Staging systems help determine prognosis and treatment options.
This document discusses liver lesions and their appearance on various imaging modalities. It covers benign lesions like hemangioma, focal nodular hyperplasia and hepatic adenoma. Malignant primary lesions discussed are hepatocellular carcinoma and hepatoblastoma. Imaging features of hypervascular and hypovascular lesions on multiphasic CT are summarized. Hepatocellular carcinoma risk factors and clinical presentation are outlined. Imaging appearance of HCC on ultrasound, CT and MRI is described in detail. Hepatic metastases are also discussed along with hypervascular metastatic lesions.
Hepatocellular carcinoma is the most common primary liver tumor. Risk factors include hepatitis B and C infections, alcohol use, and exposure to aflatoxins. It typically presents with nonspecific symptoms in patients with underlying liver disease or cirrhosis. Diagnosis involves blood tests like alpha-fetoprotein along with imaging modalities. Treatment options depend on tumor stage and liver function, and may include surgical resection, liver transplantation, ablation, or chemoembolization. Prevention focuses on hepatitis B vaccination and screening high-risk groups to detect cancer early.
Hepatocellular carcinoma (HCC) is the most common type of liver cancer. It is the fifth most common cancer worldwide and the third leading cause of cancer death. The main risk factors are hepatitis B, hepatitis C, alcoholism, and cirrhosis. HCC often develops from chronic liver inflammation and regeneration caused by these conditions. Patients may present with non-specific symptoms like abdominal pain, weight loss, and fatigue. Diagnosis involves blood tests, imaging studies, and biopsy. Prognosis is generally poor, with most patients dying within 2 years from cancer progression or liver failure.
Hepatocellular carcinoma is a primary cancer of the liver that is commonly associated with cirrhosis and hepatitis. Common causes include cirrhosis from various sources, chronic hepatitis B or C infection, and alcohol consumption. Symptoms can include abdominal pain, weight loss, jaundice, and nausea. Diagnosis involves imaging such as CT or MRI scans of the liver along with blood tests. Treatment options depend on factors like tumor size and liver function, and may include resection, transplantation, ablation, embolization, or chemotherapy. Prognosis can be assessed using scoring systems like the Child-Pugh score.
The document discusses hepatocellular carcinoma (HCC). It is the most common type of primary liver cancer, accounting for 90% of cases. Risk factors include cirrhosis of the liver caused by hepatitis B, hepatitis C, alcohol use, and non-alcoholic fatty liver disease. Chronic hepatitis B infection significantly increases the risk. The risk of developing HCC is also higher in men than women and increases with age. Precancerous lesions can develop due to chronic liver damage and increase the risk of HCC.
This document provides an overview of the management of hepatocellular carcinoma (HCC). It discusses the epidemiology, risk factors, diagnosis and staging, as well as treatment options for HCC. The major risk factors for HCC include hepatitis B virus, hepatitis C virus, and alcohol. Treatment depends on the stage and includes options such as liver transplantation, resection, ablation, transarterial chemoembolization, and the systemic therapy sorafenib. Prevention through vaccination and treating underlying liver diseases can help reduce cases of HCC.
Hepatocellular carcinoma (HCC) is a major cause of cancer mortality worldwide, with over 800,000 deaths annually. Risk factors include chronic hepatitis B and C infection, cirrhosis, and aflatoxin exposure. HCC commonly presents between ages 40-70 and is more common in men. Diagnosis involves imaging such as ultrasound, CT, or MRI showing typical arterial enhancement and washout. Serum markers AFP and DCP are also used. Surveillance is recommended for high risk groups like cirrhotic patients. Staging systems help determine prognosis and treatment options.
This document discusses liver lesions and their appearance on various imaging modalities. It covers benign lesions like hemangioma, focal nodular hyperplasia and hepatic adenoma. Malignant primary lesions discussed are hepatocellular carcinoma and hepatoblastoma. Imaging features of hypervascular and hypovascular lesions on multiphasic CT are summarized. Hepatocellular carcinoma risk factors and clinical presentation are outlined. Imaging appearance of HCC on ultrasound, CT and MRI is described in detail. Hepatic metastases are also discussed along with hypervascular metastatic lesions.
Hepatocellular carcinoma is the most common primary liver tumor. Risk factors include hepatitis B and C infections, alcohol use, and exposure to aflatoxins. It typically presents with nonspecific symptoms in patients with underlying liver disease or cirrhosis. Diagnosis involves blood tests like alpha-fetoprotein along with imaging modalities. Treatment options depend on tumor stage and liver function, and may include surgical resection, liver transplantation, ablation, or chemoembolization. Prevention focuses on hepatitis B vaccination and screening high-risk groups to detect cancer early.
Hepatocellular carcinoma (HCC) is the most common type of liver cancer. It is the fifth most common cancer worldwide and the third leading cause of cancer death. The main risk factors are hepatitis B, hepatitis C, alcoholism, and cirrhosis. HCC often develops from chronic liver inflammation and regeneration caused by these conditions. Patients may present with non-specific symptoms like abdominal pain, weight loss, and fatigue. Diagnosis involves blood tests, imaging studies, and biopsy. Prognosis is generally poor, with most patients dying within 2 years from cancer progression or liver failure.
Hepatocellular carcinoma is a primary cancer of the liver that is commonly associated with cirrhosis and hepatitis. Common causes include cirrhosis from various sources, chronic hepatitis B or C infection, and alcohol consumption. Symptoms can include abdominal pain, weight loss, jaundice, and nausea. Diagnosis involves imaging such as CT or MRI scans of the liver along with blood tests. Treatment options depend on factors like tumor size and liver function, and may include resection, transplantation, ablation, embolization, or chemotherapy. Prognosis can be assessed using scoring systems like the Child-Pugh score.
The document discusses hepatocellular carcinoma (HCC). It is the most common type of primary liver cancer, accounting for 90% of cases. Risk factors include cirrhosis of the liver caused by hepatitis B, hepatitis C, alcohol use, and non-alcoholic fatty liver disease. Chronic hepatitis B infection significantly increases the risk. The risk of developing HCC is also higher in men than women and increases with age. Precancerous lesions can develop due to chronic liver damage and increase the risk of HCC.
This document provides an overview of the management of hepatocellular carcinoma (HCC). It discusses the epidemiology, risk factors, diagnosis and staging, as well as treatment options for HCC. The major risk factors for HCC include hepatitis B virus, hepatitis C virus, and alcohol. Treatment depends on the stage and includes options such as liver transplantation, resection, ablation, transarterial chemoembolization, and the systemic therapy sorafenib. Prevention through vaccination and treating underlying liver diseases can help reduce cases of HCC.
This document outlines a seminar plan on carcinoma of the pancreas presented by Dr. Jyotindra Singh. The seminar will cover topics such as the anatomy and surgical anatomy of the pancreas, pancreatic tumors, modes of presentation, pre-operative workup, various surgeries and surgical videos, recent updates, studies and trials, and a take home message. The seminar introduction discusses that carcinoma of the exocrine pancreas accounts for over 90% of pancreatic tumors and remains an oncologic challenge with a 5-year survival rate of 3%.
This document discusses the evaluation and management of cystic tumors of the pancreas. It notes that the most common types are serous cystadenomas, mucinous cystic neoplasms, and intraductal papillary mucinous neoplasms. Initial imaging includes MRI with MRCP and EUS with FNA to characterize the cyst. Cyst fluid analysis is important to distinguish malignant potential. Small asymptomatic cysts may only need follow up imaging. Surveillance is recommended for certain non-surgical cases, monitoring for changes or malignant progression over multiple years.
Carcinoma of the stomach is usually suspected based on symptoms like abdominal pain or indigestion. Investigations include endoscopy with biopsy, which is the gold standard for diagnosis. Staging involves endoscopic ultrasound, CT, PET scans and laparoscopy. Treatment depends on the stage, and may involve surgery such as gastrectomy with lymph node dissection, adjuvant chemotherapy and/or radiotherapy. Prognosis depends on factors like stage, lymph node involvement and response to treatment, with 5-year survival rates ranging from 95% for early stage to near 0% for metastatic disease.
1. Carcinoma of the gallbladder is a rare but aggressive cancer, usually diagnosed at an advanced stage with poor median survival. Risk factors include gallstones, chronic infection, and obesity.
2. Surgical resection offers the only potential for cure, but most patients are not candidates due to advanced disease at presentation. Neoadjuvant chemotherapy may help some locally advanced tumors become resectable.
3. For unresectable or metastatic disease, palliative chemotherapy with gemcitabine and cisplatin provides modest survival benefits. Supportive care focuses on relieving biliary obstruction and other symptoms.
This document discusses primary lymphomas of the gastrointestinal tract. It begins by providing background on lymphomas and noting that the gastrointestinal tract is a common extra-nodal site. The most common subtypes of primary GI lymphomas are then described, including their typical locations and risk factors. Diagnostic workup, staging systems, treatments, and outcomes are outlined for several subtypes affecting different areas of the GI tract, such as diffuse large B-cell lymphoma and MALT lymphoma in the stomach, and immunoproliferative small intestinal disease. Throughout, key points are illustrated with images and tables.
Pancreatic cancer is the second most common gastrointestinal malignancy in the US. Risk factors include increasing age, male gender, African American race, smoking, obesity, and diabetes. The most common type is ductal adenocarcinoma, which accounts for 85-90% of cases. Overall survival is poor, with a 5-year rate of only 5%, due to most cases being diagnosed at an advanced stage when surgical resection is no longer an option.
This document provides information on cholangiocarcinoma (CCA), a malignant tumor of the bile ducts. It discusses the epidemiology, risk factors, classification, molecular pathogenesis, clinical features, diagnosis and imaging of CCA. CCA can be intrahepatic, perihilar or distal. Risk factors include primary sclerosing cholangitis, hepatolithiasis, liver fluke infections and bile duct cysts. Diagnosis involves tumor markers like CA19-9 and imaging modalities like ultrasound, CT and MRI to detect lesions. Molecular testing helps characterize mutations in genes like KRAS, TP53 and IDH1/2 involved in CCA pathogenesis.
This document provides information on testicular tumors, including their epidemiology, risk factors, classification, types, clinical features, investigations, staging, and spread. Some key points:
- Testicular tumors comprise 1-2% of all malignancies and 95% are germ cell tumors (GCTs), which predominantly affect young males.
- Risk factors include cryptorchidism, family history, prior testicular cancer, intratubular germ cell neoplasia, and environmental exposures.
- The main types of GCTs are seminoma, embryonal carcinoma, choriocarcinoma, yolk sac tumor, and teratoma.
- Clinical features depend on whether the
Carcinoid tumors are slow-growing neuroendocrine tumors that commonly arise in the gastrointestinal tract and lungs. The document discusses carcinoid tumors in depth, including their definition, sites of origin, histology, staging, clinical features, diagnostic testing, and management approaches. Treatment involves surgical resection when possible, with additional therapies for advanced or metastatic disease aimed at controlling hormone secretion and tumor growth.
This document provides information about bladder carcinoma, including:
1. Bladder carcinoma is the most common cancer of the urinary tract, affecting men more than women. It is most common in the elderly, around ages 67-70.
2. Risk factors include family history, chemical exposure, smoking, irradiation, arsenic exposure, and urinary disorders. Preneoplastic abnormalities and carcinoma in situ can develop.
3. Transitional cell carcinoma accounts for 90% of bladder cancers and can range from low to high grade. Staging involves determining if the cancer is superficial, invasive, or metastatic. Treatment depends on the stage and grade.
This document provides guidelines for the diagnosis and management of cystic pancreatic lesions. It discusses various types of cystic masses that can occur in the pancreas such as pseudocysts, serous cystadenomas, mucinous cystic neoplasms, intraductal papillary mucinous neoplasms (IPMN), and solid pseudo-papillary tumors. For each type, it provides information on characteristics, malignant potential, imaging appearance, and treatment approach. Initial evaluation of pancreatic cysts should aim to exclude pseudocysts based on history of pancreatitis. Morphological evaluation and cyst fluid analysis via EUS and FNA are important diagnostic tools to characterize cyst type and guide management.
The stomach J-shaped. It has two surfaces (the anterior & posterior), two curvatures (the greater & lesser), two orifices (the cardia & pylorus). It has fundus, body and pyloric antrum.
Blood supply
The left gastric artery
Right gastric artery
Right gastro-epiploic artery
Left gastro-epiploic artery
Short gastric arteries
Stomach cancer begins when cancer cells form in the inner lining of your stomach. These cells can grow into a tumor. Also called gastric cancer, the disease usually grows slowly over many years.
It could be:
malignant or benign
primary or secondary
This document summarizes key information about hepatocellular carcinoma (HCC). It discusses the etiology and pathogenesis of HCC. It describes the role of tumor tissue analysis in diagnosing HCC and assessing prognosis. Gross morphology, histological subtypes, and morphological parameters are reviewed. The importance of distinguishing HCC from other nodular lesions and metastases is covered. Biomarkers and the role of liquid biopsies are also mentioned.
Management of Advances Hepatocellular CarcinomaPratap Tiwari
Hepatocellular carcinoma (HCC) is a leading cause of cancer death worldwide. For advanced HCC that cannot be treated with surgery or transplantation, the standard of care has been sorafenib. Lenvatinib and cabozantinib have also shown efficacy in advanced HCC. Immunotherapy with nivolumab has shown promise based on phase II data. Combination therapies and future targeted agents may provide additional treatment options for this difficult to treat cancer.
1) Cancers of the gastroesophageal junction are either adenocarcinomas or squamous cell carcinomas. Adenocarcinomas arise from Barrett's esophagus, an abnormal change in the esophageal lining, while squamous cell carcinomas are preceded by dysplasia.
2) Endoscopic ultrasound and diagnostic laparoscopy are used to accurately stage gastroesophageal junction cancers before deciding if the cancer can be surgically removed.
3) The type of surgery performed depends on the location and stage of the cancer, with tumors closer to the stomach treated more like gastric cancers and those higher up treated like esophageal cancers. The goal is to remove the cancer and nearby lymph nodes.
management of hepatocellular carcinoma Sujay Susikar
The document provides information on hepatocellular carcinoma (HCC) including its epidemiology, etiology, risk factors, staging systems, surveillance, diagnosis, treatment options and surgical approaches. It discusses that HCC is the 5th most common cancer worldwide with the major risk factors being hepatitis B, cirrhosis, and alcohol. Staging systems covered include TNM, Okuda, CLIP and BCLC. Treatment options depend on tumor stage and liver function/reserve and may include resection, ablation, transarterial chemoembolization or transplantation. Surgical approaches to resection involve either anatomical or atypical resections.
This document provides information about carcinoma of the esophagus, including its epidemiology, risk factors, pathological classification, clinical features, investigations, diagnosis and staging, and treatment. Carcinoma of the esophagus is most common in China, South Africa, and parts of India. It typically presents with dysphagia. Investigations include endoscopy with biopsy, imaging like CT and PET scans, and endoscopic ultrasound. Treatment depends on the stage, with surgery or chemoradiation used for early-stage or locally advanced carcinoma, and palliative approaches for metastatic disease.
El hepatocarcinoma tiene la mayor tasa de incidencia en Asia. Un marcador tumoral relacionado es la alfafetoproteína. Los principales factores de riesgo son la infección crónica por virus de la hepatitis B y C, el consumo de alcohol y la ingesta de aflatoxinas. Las pruebas funcionales hepáticas más útiles son la determinación de la cinética de bromosulfaleína y la prueba de clareamiento de colorante. Algunas clasificaciones utilizadas son Okuda, BCLC, CLIP y CUPI.
This document outlines a seminar plan on carcinoma of the pancreas presented by Dr. Jyotindra Singh. The seminar will cover topics such as the anatomy and surgical anatomy of the pancreas, pancreatic tumors, modes of presentation, pre-operative workup, various surgeries and surgical videos, recent updates, studies and trials, and a take home message. The seminar introduction discusses that carcinoma of the exocrine pancreas accounts for over 90% of pancreatic tumors and remains an oncologic challenge with a 5-year survival rate of 3%.
This document discusses the evaluation and management of cystic tumors of the pancreas. It notes that the most common types are serous cystadenomas, mucinous cystic neoplasms, and intraductal papillary mucinous neoplasms. Initial imaging includes MRI with MRCP and EUS with FNA to characterize the cyst. Cyst fluid analysis is important to distinguish malignant potential. Small asymptomatic cysts may only need follow up imaging. Surveillance is recommended for certain non-surgical cases, monitoring for changes or malignant progression over multiple years.
Carcinoma of the stomach is usually suspected based on symptoms like abdominal pain or indigestion. Investigations include endoscopy with biopsy, which is the gold standard for diagnosis. Staging involves endoscopic ultrasound, CT, PET scans and laparoscopy. Treatment depends on the stage, and may involve surgery such as gastrectomy with lymph node dissection, adjuvant chemotherapy and/or radiotherapy. Prognosis depends on factors like stage, lymph node involvement and response to treatment, with 5-year survival rates ranging from 95% for early stage to near 0% for metastatic disease.
1. Carcinoma of the gallbladder is a rare but aggressive cancer, usually diagnosed at an advanced stage with poor median survival. Risk factors include gallstones, chronic infection, and obesity.
2. Surgical resection offers the only potential for cure, but most patients are not candidates due to advanced disease at presentation. Neoadjuvant chemotherapy may help some locally advanced tumors become resectable.
3. For unresectable or metastatic disease, palliative chemotherapy with gemcitabine and cisplatin provides modest survival benefits. Supportive care focuses on relieving biliary obstruction and other symptoms.
This document discusses primary lymphomas of the gastrointestinal tract. It begins by providing background on lymphomas and noting that the gastrointestinal tract is a common extra-nodal site. The most common subtypes of primary GI lymphomas are then described, including their typical locations and risk factors. Diagnostic workup, staging systems, treatments, and outcomes are outlined for several subtypes affecting different areas of the GI tract, such as diffuse large B-cell lymphoma and MALT lymphoma in the stomach, and immunoproliferative small intestinal disease. Throughout, key points are illustrated with images and tables.
Pancreatic cancer is the second most common gastrointestinal malignancy in the US. Risk factors include increasing age, male gender, African American race, smoking, obesity, and diabetes. The most common type is ductal adenocarcinoma, which accounts for 85-90% of cases. Overall survival is poor, with a 5-year rate of only 5%, due to most cases being diagnosed at an advanced stage when surgical resection is no longer an option.
This document provides information on cholangiocarcinoma (CCA), a malignant tumor of the bile ducts. It discusses the epidemiology, risk factors, classification, molecular pathogenesis, clinical features, diagnosis and imaging of CCA. CCA can be intrahepatic, perihilar or distal. Risk factors include primary sclerosing cholangitis, hepatolithiasis, liver fluke infections and bile duct cysts. Diagnosis involves tumor markers like CA19-9 and imaging modalities like ultrasound, CT and MRI to detect lesions. Molecular testing helps characterize mutations in genes like KRAS, TP53 and IDH1/2 involved in CCA pathogenesis.
This document provides information on testicular tumors, including their epidemiology, risk factors, classification, types, clinical features, investigations, staging, and spread. Some key points:
- Testicular tumors comprise 1-2% of all malignancies and 95% are germ cell tumors (GCTs), which predominantly affect young males.
- Risk factors include cryptorchidism, family history, prior testicular cancer, intratubular germ cell neoplasia, and environmental exposures.
- The main types of GCTs are seminoma, embryonal carcinoma, choriocarcinoma, yolk sac tumor, and teratoma.
- Clinical features depend on whether the
Carcinoid tumors are slow-growing neuroendocrine tumors that commonly arise in the gastrointestinal tract and lungs. The document discusses carcinoid tumors in depth, including their definition, sites of origin, histology, staging, clinical features, diagnostic testing, and management approaches. Treatment involves surgical resection when possible, with additional therapies for advanced or metastatic disease aimed at controlling hormone secretion and tumor growth.
This document provides information about bladder carcinoma, including:
1. Bladder carcinoma is the most common cancer of the urinary tract, affecting men more than women. It is most common in the elderly, around ages 67-70.
2. Risk factors include family history, chemical exposure, smoking, irradiation, arsenic exposure, and urinary disorders. Preneoplastic abnormalities and carcinoma in situ can develop.
3. Transitional cell carcinoma accounts for 90% of bladder cancers and can range from low to high grade. Staging involves determining if the cancer is superficial, invasive, or metastatic. Treatment depends on the stage and grade.
This document provides guidelines for the diagnosis and management of cystic pancreatic lesions. It discusses various types of cystic masses that can occur in the pancreas such as pseudocysts, serous cystadenomas, mucinous cystic neoplasms, intraductal papillary mucinous neoplasms (IPMN), and solid pseudo-papillary tumors. For each type, it provides information on characteristics, malignant potential, imaging appearance, and treatment approach. Initial evaluation of pancreatic cysts should aim to exclude pseudocysts based on history of pancreatitis. Morphological evaluation and cyst fluid analysis via EUS and FNA are important diagnostic tools to characterize cyst type and guide management.
The stomach J-shaped. It has two surfaces (the anterior & posterior), two curvatures (the greater & lesser), two orifices (the cardia & pylorus). It has fundus, body and pyloric antrum.
Blood supply
The left gastric artery
Right gastric artery
Right gastro-epiploic artery
Left gastro-epiploic artery
Short gastric arteries
Stomach cancer begins when cancer cells form in the inner lining of your stomach. These cells can grow into a tumor. Also called gastric cancer, the disease usually grows slowly over many years.
It could be:
malignant or benign
primary or secondary
This document summarizes key information about hepatocellular carcinoma (HCC). It discusses the etiology and pathogenesis of HCC. It describes the role of tumor tissue analysis in diagnosing HCC and assessing prognosis. Gross morphology, histological subtypes, and morphological parameters are reviewed. The importance of distinguishing HCC from other nodular lesions and metastases is covered. Biomarkers and the role of liquid biopsies are also mentioned.
Management of Advances Hepatocellular CarcinomaPratap Tiwari
Hepatocellular carcinoma (HCC) is a leading cause of cancer death worldwide. For advanced HCC that cannot be treated with surgery or transplantation, the standard of care has been sorafenib. Lenvatinib and cabozantinib have also shown efficacy in advanced HCC. Immunotherapy with nivolumab has shown promise based on phase II data. Combination therapies and future targeted agents may provide additional treatment options for this difficult to treat cancer.
1) Cancers of the gastroesophageal junction are either adenocarcinomas or squamous cell carcinomas. Adenocarcinomas arise from Barrett's esophagus, an abnormal change in the esophageal lining, while squamous cell carcinomas are preceded by dysplasia.
2) Endoscopic ultrasound and diagnostic laparoscopy are used to accurately stage gastroesophageal junction cancers before deciding if the cancer can be surgically removed.
3) The type of surgery performed depends on the location and stage of the cancer, with tumors closer to the stomach treated more like gastric cancers and those higher up treated like esophageal cancers. The goal is to remove the cancer and nearby lymph nodes.
management of hepatocellular carcinoma Sujay Susikar
The document provides information on hepatocellular carcinoma (HCC) including its epidemiology, etiology, risk factors, staging systems, surveillance, diagnosis, treatment options and surgical approaches. It discusses that HCC is the 5th most common cancer worldwide with the major risk factors being hepatitis B, cirrhosis, and alcohol. Staging systems covered include TNM, Okuda, CLIP and BCLC. Treatment options depend on tumor stage and liver function/reserve and may include resection, ablation, transarterial chemoembolization or transplantation. Surgical approaches to resection involve either anatomical or atypical resections.
This document provides information about carcinoma of the esophagus, including its epidemiology, risk factors, pathological classification, clinical features, investigations, diagnosis and staging, and treatment. Carcinoma of the esophagus is most common in China, South Africa, and parts of India. It typically presents with dysphagia. Investigations include endoscopy with biopsy, imaging like CT and PET scans, and endoscopic ultrasound. Treatment depends on the stage, with surgery or chemoradiation used for early-stage or locally advanced carcinoma, and palliative approaches for metastatic disease.
El hepatocarcinoma tiene la mayor tasa de incidencia en Asia. Un marcador tumoral relacionado es la alfafetoproteína. Los principales factores de riesgo son la infección crónica por virus de la hepatitis B y C, el consumo de alcohol y la ingesta de aflatoxinas. Las pruebas funcionales hepáticas más útiles son la determinación de la cinética de bromosulfaleína y la prueba de clareamiento de colorante. Algunas clasificaciones utilizadas son Okuda, BCLC, CLIP y CUPI.
This document provides an overview of hepatocellular carcinoma (HCC). It discusses the anatomy, epidemiology, screening, diagnosis, staging and management of HCC. HCC is commonly caused by viral hepatitis and cirrhosis. Diagnosis involves imaging such as ultrasound, CT or MRI showing characteristic arterial enhancement and venous washout. Staging systems include AJCC, Okuda, CLIP and BCLC which incorporate tumor burden, liver function and performance status. Management options include surgical resection, liver transplantation, ablation and arterially directed therapies like TACE.
Presentacion del Residente Jose Chavez Peche en las reuniones de los residentes de Cirugia General y Digestiva del Hospital Nacional Edgardo Rebagliati EsSALUD Lima Perú. Jefe del Departamento Iván Vojvodic
The document discusses a case of hepatocellular carcinoma (HCC) in a 68-year-old male patient. Imaging revealed a solitary liver lesion with characteristics of HCC on CT scan. Given the patient's good performance status and the localized nature of the disease, he underwent a right posterior sectionectomy. Histopathology confirmed HCC. The patient recovered well post-operatively without major complications. Surgical resection can provide cure for select patients with HCC, especially when the tumor is localized and the patient's liver function is preserved.
1. Cervical cancer is the third most common cancer in women worldwide and the second leading cause of cancer death in women globally, with most cases occurring in developing countries.
2. Screening programs have helped lower cervical cancer incidence rates in developed countries by enabling early detection. The human papillomavirus (HPV) is the most important risk factor for cervical cancer.
3. Treatment for cervical cancer depends on the stage and includes surgery, chemotherapy, radiation therapy, or concurrent chemoradiation. Concurrent chemoradiation has been shown to improve outcomes compared to radiation alone or radiation with chemotherapy for locally advanced cervical cancer.
This document provides an overview of adrenal gland imaging and differentiation of benign and malignant adrenal masses. It discusses normal adrenal gland anatomy and histology. Common imaging modalities for adrenal masses are CT, MRI, ultrasound, and PET. Benign adrenal adenomas typically appear homogeneous with rapid contrast washout on CT. Malignant masses tend to be heterogeneous with delayed washout. Specific adrenal tumors discussed include adenomas, metastases, myelolipomas, and lymphoma. Features on various imaging modalities that help characterize each tumor are presented.
Approach to cushing syndrome dr vidyakarSachin Verma
Dr. Sachin Verma is a consultant in internal medicine and critical care. His areas of fellowship include intensive care medicine and infection control. He provides consultation services and can be reached by phone or through his website. The document then provides information on investigating and approaching a case of Cushing's syndrome, including classifications, etiologies, symptoms, investigation algorithms, imaging modalities, and treatment options.
1) The document discusses workup, classification, prognostic factors, and treatment approaches for non-Hodgkin lymphoma. It covers topics such as immunohistochemistry panels, cell morphology, genetic markers, and clinical staging systems.
2) Treatment recommendations are provided for different subtypes and stages of NHL, including chemotherapy regimens and use of radiation therapy. Factors like tumor bulk and response to initial treatment are considered for determining subsequent treatment steps.
3) Guidelines for management of refractory or relapsed NHL address options like high-dose chemotherapy, radiation, second-line chemotherapy regimens, clinical trials, and autologous stem cell transplant.
The document provides an overview of the Egyptian HCC Guidelines presented by Mohamed A. Ezzel Arab MD. It summarizes the guidelines on primary, secondary, and tertiary prevention of HCC. It also outlines recommendations for screening, diagnosis, staging, treatment including surgical resection, locoregional therapies, transplantation, and systemic therapies. Post-treatment monitoring guidelines are also presented. The document aims to provide evidence-based guidelines tailored to factors in Egypt based on international guidelines and expert opinion.
This document summarizes Hodgkin lymphoma (HL), including its epidemiology, histology, clinical presentation, workup, staging, prognosis, and treatment. HL is a common lymphoma that represents about 11% of all lymphomas. It predominantly affects young adults and is associated with Epstein-Barr virus. The hallmark is the Reed-Sternberg cell. Treatment involves chemotherapy such as ABVD or BEACOPP, with radiation therapy used for early or advanced stage disease. Prognosis depends on staging, with 5-year survival rates over 85% for early stage disease treated with chemotherapy and radiation.
This document discusses B cell lymphoma and its classification. It notes that lymphomas are malignant disorders derived from lymphoid cells that can be B cell or T cell in origin, with the majority being of B cell origin. B cell lymphomas are divided into Hodgkin's lymphoma and non-Hodgkin's lymphoma. Hodgkin's lymphoma is a distinct malignant disease that is predominantly of B cell origin and has a variable disease course but improved prognosis with modern treatments. Non-Hodgkin's lymphomas are more often clinically disseminated at diagnosis and can be of B cell or T cell origin.
Anselmo A. Cirrosi Epatica e Tumori del Fegato: dalla Resezione al Trapianto....Gianfranco Tammaro
The document discusses cirrhosis and liver tumors, from resection to transplantation. It covers:
- The epidemiology of liver cancer, including risk factors, global incidence, and age-specific incidence.
- The pathogenesis and risk factors involved in the development of hepatocellular carcinoma (HCC).
- The clinical features, diagnosis, and management of HCC according to guidelines from EASL and other sources.
- Treatment options for HCC including resection, transplantation, and prevention.
Kinds of Liver Cancers diagnosis and TreatementsSumit Roy
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
This document provides definitions and overview of various cystic kidney diseases including simple cysts, autosomal dominant polycystic kidney disease (ADPKD), autosomal recessive polycystic kidney disease (ARPKD), acquired cystic kidney disease, Alport's syndrome, medullary sponge kidney, medullary cystic kidney disease, and renal phacomatosis associated with tuberous sclerosis and Von Hippel-Lindau disease. It describes the clinical features, pathogenesis, diagnosis, and management of these conditions.
This document provides definitions and overview of various cystic kidney diseases including simple cysts, autosomal dominant polycystic kidney disease (ADPKD), autosomal recessive polycystic kidney disease (ARPKD), acquired cystic kidney disease, Alport's syndrome, medullary sponge kidney, medullary cystic kidney disease, and renal phacomatosis associated with tuberous sclerosis and Von Hippel-Lindau disease. It describes the clinical features, pathogenesis, diagnosis, and management of these conditions.
Hodgkins lymphoma history, physical exam and managementLajpat Rai
- The patient is a 13-year-old male who presented with 1 year of fever and 6 months of weight loss.
- Examination found enlarged cervical lymph nodes. Investigations revealed anemia and elevated ESR. Imaging showed mediastinal lymphadenopathy.
- Excisional biopsy of a cervical lymph node found Hodgkin's lymphoma of the mixed cellularity type.
- Treatment involves chemotherapy with ABVD, with radiotherapy added for more advanced stages. Prognosis is generally good, though long term survivors are at risk of late effects from treatment.
This document discusses adrenal incidentalomas, which are adrenal masses greater than 1cm discovered incidentally on imaging. It covers the epidemiology, risks of progression, imaging techniques, and assessment of hormonal functionality. For hormonally inactive incidentalomas, the risks of malignancy and developing hormonal hypersecretion are low. Dedicated adrenal imaging can help characterize lesions and determine need for follow up. Biochemical testing assesses for hormonal hypersecretion from conditions like pheochromocytoma, Cushing's syndrome, and primary hyperaldosteronism. Subclinical Cushing's syndrome is defined and testing approaches are outlined. Surgical resection may be considered for larger lesions or biochemically active
HCC Clinical update and hints from AASLD 2017 guidelines mainly about surveillance, diagnosis and treatment of Hepatocellular carcinoma in different stages.
Triphasic CT (TPCT) Scan of the liver is essential in view of the dual blood supply of the liver. TPCT allows characterisaiton of all liver lesions and close to pathological correlaiton by non invasive imaging alone. Additionally providing segmental vascular analysis as a surgicical guide.
1) Cirrhosis of the liver complicates imaging due to the increased risk of hepatocellular carcinoma (HCC) and the presence of other lesions that can mimic HCC.
2) While most HCCs enhance on arterial phase imaging, up to 15% are hypovascular and imaging techniques must be optimized to properly detect tumors.
3) Benign lesions like regenerative nodules, focal fibrosis, and vascular abnormalities are common in cirrhotic livers and can appear similar to HCC, so attention to characteristics on all phases is important to avoid misdiagnosis.
This document summarizes current approaches to diagnosing small hepatocellular carcinoma (HCC) in patients with liver cirrhosis. It discusses that cirrhosis is associated with an increased risk of HCC due to factors like hepatitis B, C, alcohol, and non-alcoholic fatty liver disease. Guidelines recommend ultrasound surveillance every 6 months for HCC detection in cirrhotic patients. While ultrasound has reasonable sensitivity, specificity is improved when combined with tumor markers or additional imaging modalities. The document reviews vascular changes, imaging features, and protocols for CT, MRI, and contrast agents that optimize detection of small HCCs in this high-risk population.
The document describes the case of a 26-year-old female who presented with shortness of breath and was initially diagnosed with anxiety but later diagnosed with acute pulmonary thromboembolism. It then reviews the epidemiology, pathophysiology, risk factors, clinical features, diagnosis, natural history, and management of acute pulmonary thromboembolism, with a focus on topics relevant to critically ill patients.
This document summarizes the debate around providing adjuvant chemotherapy following neoadjuvant chemoradiotherapy for rectal cancer. It outlines the current treatment approaches and evidence for and against adjuvant chemotherapy. Studies have shown conflicting results as to whether adding oxaliplatin to adjuvant chemotherapy improves outcomes. Large trials comparing adjuvant chemotherapy to observation alone did not find significant differences in survival or recurrence, though a meta-analysis found a small improvement in disease-free survival with chemotherapy. The author concludes that for locally advanced rectal cancer treated with neoadjuvant chemoradiotherapy, adjuvant chemotherapy is indicated for high-risk pathologic stage II/III tumors but the benefits are less clear for lower-risk cases.
This presentation covers the guidelines for follow up of patients with Hodgkin's lymphoma after they achieve complete remission and complete their therapy.
This document provides guidance on writing a thesis, including sections to include, formatting, and style. It outlines the typical structure of a thesis as an introduction, literature review, methods, results, discussion, and conclusions. It discusses elements that should be included in each section, such as stating the research question in the introduction and summarizing results in the conclusions. The document also provides examples of formatting requirements for the title page, table of contents, and references. Key recommendations include using the Harvard referencing style and 1.5 line spacing for the English version.
This document provides an overview of referencing and citation styles. It discusses why references are important, the different components of citations and references, and the key styles including alphabetical (e.g. Harvard) and numbered (e.g. Vancouver). The agenda covers citation items like quotations and paraphrasing, categories of styles, examples of references, and referencing software. The goal is to teach researchers how to properly cite sources and format reference lists in manuscripts and protocols.
This is an overview of the adjuvant Tx of pancreatic CA. A Lecture that was given in the annual conference of NCI Egypt: 45 years against cancer in Egypt. Cairo, April, 2013
This document provides an introduction to clinical research and good clinical practice (GCP). It discusses the types of scientific and clinical research, including observational and experimental study designs. The document outlines the phases of clinical trials from I to IV. It emphasizes the importance of ethics in research and describes GCP as international ethical and quality standards for clinical research. GCP aims to protect research participants and ensure valid, reliable results. The document lists the parties involved in clinical research, including investigators, sponsors, and ethics committees, and their roles and responsibilities.
Bone sarcomas are rare cancers that can be curable if treated properly. The main types are osteosarcoma, Ewing sarcoma, and chondrosarcoma. Staging involves imaging and biopsy to determine tumor size, location, and spread. Multidisciplinary teams are needed for optimal care. Chemotherapy is important for osteosarcoma and Ewing sarcoma but not usually effective for chondrosarcoma. Neoadjuvant chemotherapy followed by surgery improves outcomes for osteosarcoma over surgery alone. Short and long chemotherapy regimens appear equally effective for operable osteosarcoma. Ifosfamide added to standard regimens improves outcomes for non-metastatic and
This document discusses soft tissue sarcomas (STS), including:
- Incidence rates in the US and Egypt. Radiation therapy is a risk factor.
- Common primary and metastatic sites vary by tumor type.
- STS originate from mesenchymal cells and include many subtypes.
- Diagnosis involves biopsy, imaging, and genetic testing to identify specific mutations in certain sarcoma subtypes.
- Treatment depends on grade and stage but commonly involves surgery with or without chemotherapy and/or radiation therapy. Outcomes vary significantly by histology, grade, and other factors.
Melanoma arises from neural crest cells that migrate and produce the pigment melanin. It can present in skin or mucosal surfaces and commonly spreads from radial to vertical growth phases as it invades deeper tissues. Treatment depends on tumor stage and characteristics as well as mutation status, and may involve surgery, radiation, immunotherapy, targeted therapy, or chemotherapy.
The study evaluated annual low-dose helical CT screening versus standard chest x-ray for lung cancer screening in high-risk individuals aged 55-74 years who were heavy smokers. Over 53,000 participants were randomized across 33 sites in the U.S. The trial was stopped early based on a recommendation when interim results found a 20% reduction in lung cancer mortality with CT screening. CT screening found more positive cases but also had higher false positive rates compared to chest x-ray.
This document discusses gastric cancer staging, treatment, and clinical trials. It begins with an overview of TNM staging for gastric cancer. The main treatment approaches discussed are surgery, chemotherapy, and chemoradiotherapy in both adjuvant and neoadjuvant settings. Key clinical trials summarized include the MAGIC trial demonstrating improved survival with perioperative chemotherapy and the INT-0116 trial showing benefit of postoperative chemoradiotherapy. Later lines of chemotherapy discussed include regimens using fluoropyrimidines, platinum agents, taxanes, and irinotecan. The ToGA trial established the benefit of adding trastuzumab for HER2-positive gastric cancer.
1) Evaluating scientific literature is important due to the huge volume of new articles published each year. It is necessary to prioritize what to read in order to acquire the most relevant information.
2) There are different types of information sources, including primary sources which are original research articles, secondary sources which discuss primary sources, and tertiary sources which discuss secondary sources.
3) Evidence-based medicine tools like the evidence pyramid and evidence boxes can help evaluate different types of studies and quickly determine the appropriate level of evidence for answering clinical questions.
This document provides information on ovarian cancer including:
1. It describes the TNM staging system for ovarian cancer and defines each stage.
2. It discusses treatment options including surgery, chemotherapy administered intravenously or intraperitoneally, and maintenance therapy.
3. It notes that the standard treatment is intravenous chemotherapy but intraperitoneal chemotherapy may be an option for early stage III disease with residual tumor less than 1cm.
This document discusses the history of medicine from ancient times to the medieval era. It mentions several important figures such as:
- Imhotep in ancient Egypt who practiced surgery, dentistry, and extracted medicine from plants.
- Hippocrates, the father of modern medicine, who established clinical inspection, observation, and documentation as well as the Hippocratic Oath.
- Galen, a physician to the Roman emperor Marcus Aurelius, who performed early animal experiments including spinal cord transection.
- Ibn Sina (Avicenna) who made major contributions to medicine, including establishing experimental medicine.
- Ibn al-Nafis who provided an accurate description of
A 40-year-old male presented with a one-month history of worsening headaches that were unimproved by various treatments. Imaging revealed a 3x3 cm brain mass. The patient's doctor discussed the potential of a brain tumor and the need for biopsy to make a definitive diagnosis. The doctor explained that further testing would be needed to determine if the mass was a primary or secondary brain tumor, the tumor type and grade, and the most appropriate treatment plan based on factors like tumor location, size, the patient's health status, and available therapies. A pathological diagnosis would be essential before considering treatment options like surgery, radiation, chemotherapy, or a combination.
This document provides information about prostate cancer including its anatomy, grading, staging, risk classification, diagnostic workup, and treatment options. It discusses in detail Gleason scoring, TNM staging, factors that determine risk classification as localized, locally advanced, or metastatic disease. Treatment strategies are outlined depending on risk classification, including active surveillance, surgery, radiation therapy, hormone therapy, and chemotherapy. Treatment related side effects and long term outcomes are also summarized.
- Renal cell carcinoma accounts for 2-3% of all malignancies and risk factors include smoking, obesity, and von Hippel-Lindau disease.
- Treatment depends on tumor stage and includes surgery for localized disease and systemic therapies like sunitinib, sorafenib, temsirolimus, bevacizumab, and everolimus for advanced or metastatic disease.
- First line options for metastatic RCC include sunitinib for good-intermediate risk and temsirolimus for poor-risk based on MSKCC criteria; options for refractory disease include sorafenib, everolimus, and sequential targeted therapies.
Cholelithiasis is a common risk factor for gallbladder cancer. Gallbladder cancer often mimics other gallbladder conditions and is frequently diagnosed at an advanced stage. Adenocarcinoma is the most common pathology. Staging involves the TNM system and survival rates vary significantly based on stage - from a median of 12 months for stage 1 to only 1 month for stage 4. Surgery offering curative intent involves cholecystectomy with hepatic resection and lymphadenectomy, while palliative options exist for unresectable or metastatic disease. Adjuvant therapy may involve chemotherapy or chemoradiation depending on risk factors.
5. HCC and Cirrhosis
— Risk factors for HCC are also risk factors for liver cirrhosis.
— 60%-80% of HCC have cirrhosis
— Cirrhosis is a prerequisite for HCC in inherited metabolic
diseases and autoimmune D.
— annual incidence rate of HCC in hepatitis C-related cirrhosis:
2-8%.
5 Ahmed Zeeneldin
8. Screening for HCC
— Aim: Early asymptomatic curable
— China:
— Hepatitis B or history of chronic hepatitis
— Screening: AFP and US q 6m
— <60% completed the screening program (5-10 times).
— biannual screening reduced HCC mortality by 37%
— Zhang et al, J Cancer Res Clin Oncol. 2004;130:417-422.
Screening Control
N 9,373 9,443
Total HCC n 86 67
Subclinical HCC n 52 (60%) 0
Small HCC 39 (45%) 0
Resection 40 (47%) 5
OS at 1,3,5y 66, 53, 46% 31,7,0% (S)
Death 32 54 (S)
8 Ahmed Zeeneldin
9. Screening methods
— AFP and US
— US > AFP but operator dependednt
— Both are better
HCC No-HCC
test + True + False + PPV=TP/TP+FP
AFP: 5% AFP: 3%
US : 3% US : 7%
Both: 7% Both: 3%
- False – True – NPP= TN/TN+FN
Sensitivity: TP/TP+FN Specificity: TN/TN+FP
AFP: 70%
US : 85%
Both: 92%
9 Ahmed Zeeneldin
10. Indications for screening
— Patients at risk for HCC:
— Cirrhosis
— Hepatitis B, C
— Alcohol
— Genetic hemochromatosis
— Auto immune hepatitis
— Non-alcoholic steatohepatitis
— Primary biliary cirrhosis
— Alpha1-antitrypsin deficiency
— Without cirrhosis
— Hepatitis B carriers
— Non-alcoholic steatohepatitis
10 Ahmed Zeeneldin
14. Imaging of hepatic tumors
— Triphasic CT, MRI, US*
— 1-arterial phase (malignancy)
— 2-portal venous phase (normal)
— 3-venous phase after a delay
— How classic HCC look in triphasic imaging
— Arterial phase: intense arterial uptake or enhancement (White)
— Delayed veous phase: washout or hypointensity (Grey)
14 Ahmed Zeeneldin
15. CT normal liver
A eraly arterial, Hepatic artery opacified
B late arterial, portal vein opacified
C potal venous phase: middle hepatic vein opacified
15 Ahmed Zeeneldin
16. HCC CT
CT evaluation of the liver during the early arterial (2a), late arterial (2b), and portal
venous (2c) phases of enhancement.
The mass in segment III (white arrow) demonstrates the classic pattern of enhancement for
HCC.
16 Ahmed Zeeneldin
17. HCC US
(a) RT hepatic lobe hypoechoic FL
(b) Dynamic contrast enhanced US
with SonoVue. The early arterial phase
: peripheral tumoural vessels (arrows)
with enhancement filling from the
periphery.
(c) The arterial phase
: homogeneous tumoural
enhancement with a small hypoechoic
area (arrow).
(d) In the portal phase, the HCC
(arrows) became relatively hypoechoic
to the surrounding enhanced liver
parenchyma.
17 Ahmed Zeeneldin
18. HCC MRI
(A) shows the arterial phase of the MRI, indicating an arterially
enhancing mass in the right lobe of the liver near the dome (arrow), with an
enhancing rim around the mass.
18 Ahmed Zeeneldin
19. HCC MRI
(B) shows the 3-minute delayed image of the hepatic mass. The mass
appears hypointense compared with the rest of the liver (arrow), consistent
with a marked decrease in arterial blood supply to the mass. This process is
called “washout of contrast.”
19 Ahmed Zeeneldin
20. HFL in US
— Size >2cm
— One imaging modality (triphasic CT, MRI, US)
— Classic = HCC
— None classic: Bx
— Size 1-2 cm
— 2 imaging modalities:
— Both classic = HCC
— One classic: biopsy
— None classic: Bx
— Size <1cm
— One imaging modality q3-4 m
— Stable for 18 m: imaging q 6-12
— Enlarging as before
20 Ahmed Zeeneldin
21. Needle biopsy
— Sampling error, particularly 1-2 cm.
— Negative biopsy : follow up closely
21 Ahmed Zeeneldin
22. HCC staging
— M1: Distant metastasis
— N1: Regional lymph node metastasis
— T1: Solitary tumor without vascular
invasion
— T2: Solitary tumor with vascular
invasion OR
multiple tumors none more than 5 cm
— T3: Multiple tumors more than 5 cm
OR tumor involving a major branch of
the portal or hepatic vein(s)
— T4: direct invasion of adjacent organs
other than the gallbladder or with
perforation of visceral peritoneum
— F0: Fibrosis score 0-4 (none to
moderate fibrosis)
— F1: Fibrosis score 5-6 (severe fibrosis or
cirrhosis)
22 Ahmed Zeeneldin
23. Serum biomarkers
— AFP: not a sensitive or specific.
— Diagnosis of HCC should not be based solely on the AFP
level, regardless of how high it may be.
— AFP in conjunction with other tests.
— Additional imaging studies (ie, CT/MRI) with a rising serum
AFP level in the absence of a liver mass
23 Ahmed Zeeneldin
24. Serum biomarkers
— AFP: not a sensitive or specific.
— Diagnosis of HCC should not be based solely on the AFP
level, regardless of how high it may be.
— AFP in conjunction with other tests.
— Rising serum AFP level in the absence of a liver mass suggests
additional imaging studies (ie, CT/MRI)
— If still no masses: more frequent AFP and Imaging q 3 m
— Mass > 2 cm with classic imaging , AFP > 200 ng/ml: is
diagnostic of HCC
24 Ahmed Zeeneldin
25. workup
— HP
— Hepatic function?
— Portal ypertension?
— Is there hepatitis B/C?
— Comorbidities?
— Is there metastasis?
— lung, abdominal lymph nodes and the bone.
25 Ahmed Zeeneldin
26. Assessments
— liver function tests:
— Bilirubin
— Aspartate transaminase (AST),
— alanine transaminase (ALT),
— Alkaline phosphatase, lactate dehydrogenase (LDH),
— albumin, and protein.
— kidney function tests: BUN and creatinine
— Others: PT/PC or INR and CBCD
26 Ahmed Zeeneldin
27. Child-Pugh classification
Measure 1 point 2 points 3 points units
Bilirubin (total) <34 (<2) 34-50 (2-3) >50 (>3) μmol/l (mg/dl)
Serum albumin >35 28-35 <28 g/l
INR <1.7 1.71-2.20 > 2.20 no unit
Ascites None Mild Severe no unit
Grade I-II (or
Hepatic Grade III-IV (or
None suppressed with no unit
encephalopathy refractory)
medication)
One year Two year
Points Class
survival survival
5-6 A 100% 85%
7-9 B 81% 57%
10-15 C 45% 35%
27 Ahmed Zeeneldin
28. Child-Pugh classification
— Advantages
— Simple
— Includes clinical parameters (ascites, encephalopathy)
— Disadvatages
— Lacks data on portal hypertension (esophagogastric varices,
splenomegaly, abdominal collaterals)
— Clinical data are subjective
— Interpretation
— Class A: compensated cirrhosis
— Class B and C: decompensated cirrhosis
28 Ahmed Zeeneldin
29. Model for End-Stage Liver Disease (MELD)
— MELD = 3.78[Ln serum bilirubin (mg/dL)] + 11.2[Ln INR] +
9.57[Ln serum creatinine (mg/dL)] + 6.43
— Predict death within 3 months after (TIPS) surgery transjugular
intrahepatic portosystemic shunt
— 40 or more — 100% mortality
— 30–39 — 83% mortality
— 20–29 — 76% mortality
— 10–19 — 27% mortality
— <10 — 4% mortality
— Advantage:
— Includes renal function
— No subjectivity
— Prioritize liver transplant
29 Ahmed Zeeneldin
30. Pathology of HCC
— Gross
— Nodular (Cirrohsis): well
circumscribed nodules.
— Massive (noncirrhotic):
large area with or without
satellite nodules
— Diffuse: small indistinct
tumor nodules throughout
the liver.
30 Ahmed Zeeneldin
34. Prognostic Factors in HCC:
— Tumor: stage, aggressiveness and growth rate:
— AJCC TNM staging
— Patient: general health
— ECOG PS
— Karnofsky PS
— Liver: functions
— Child-Pugh, MELD
— Treatments
34 Ahmed Zeeneldin
35. Other systems
— Okuda system:
— based on tumor size, ascites, jaundice and serum albumin
— The French classification (GRETCH) system
— Karnofsky performance , measurements of liver function and
serum AFP
— Cancer of the Liver Italian Program (CLIP)
— Child-Pugh stage, tumor morphology, alpha-fetoprotein (AFP),
and portal vein thrombosis.
— Barcelona Clinic Liver Cancer (BCLC),
35 Ahmed Zeeneldin
38. Modalities
— Surgery
— Local Regional Therapy
— Bland embolization and chemoembolization
— Conformal or stereotactic radiation therapy
— Systemic therapy
— Best supportive care
38 Ahmed Zeeneldin
39. Surgery
— Partial Hepatectomy
— Early-stage HCC who are eligible to undergo the procedure.
— solitary tumors without major vascular invasion.
— 3 or fewer tumors of 3 cm or less (debateable)
— Child-Pugh A, No portal HT, adequate reserve
— Low operative morbidity and mortality (5% or less).
— 5 year OS: ~ 50%
— 5 year recurrences: ~70%
— Hepatic reserve (HR)
— Future liver remnant (FLR)
— HR=FLR/total liver volume-Tu
— =>20 % if no cirrhosis
— =>30-40 % if cirrhosis
39 Ahmed Zeeneldin
40. Surgery
— Liver Transplantation
— Potentially curative for early HCC.
— 4 y OS: 85% and 4-y RFS: 92%
— Removes detectable and undetectable lesions,
— treats underlying cirrhosis
— Avoids complications of small FLR.
— United Network for Organ Sharing (UNOS)/Milan criteria
— Patient has a tumor 5 cm in diameter or 2-3 tumors 3 cm each
— No macrovascular involvement
— No extrahepatic disease
— Child-Pugh B and C
— These patients may be resected if transplantation not feasible
Mazzaferro et al , N Engl J Med 1996;334(11):693-700.
40 Ahmed Zeeneldin
41. Surgery
— Bridge therapy
— Locoregional treatment of HCC as a bridge to liver
transplantation in eligible patients waiting for the procedure.
— radiofrequency ablation (RFA),
— Chemoembolization
— radioembolization
41 Ahmed Zeeneldin
42. Local Regional Therapy
— Aim: selective tumor necrosis,
— categories: ablation or embolization.
— They are not comparable to that of liver resection or
transplantation.
— should not be used in place of resection or transplantation for
eligible patients
42 Ahmed Zeeneldin
43. Local Regional Therapy
— Ablation: inducing direct necrosis
— Chemical : ethanol (PEI), acetic acid
— Physical: radiofrequency ablation [RFA], microwave ablation,
cryoablation
— laparoscopic, percutaneous or open approaches.
— Indications: local disease only completely amenable to ablative
therapy according to the size and location of the tumor(s).
— Major complications 5%, mortality 0%
— Tumor necrosis is assessed by CT/MRI at intervals an no
contrast uptake
43 Ahmed Zeeneldin
45. PEI vs RFA
HCC <= 4cm
RCT
Complete tumor necrosis was defined as persistent hypoattenuation of the tumor
on helical CT 4 months after the most recent ablation therapy
Lim et al, Gastroenterology. 2004 Dec;127(6):1714-23.
Conventional PEI Higher dose PEI RFA
52 (64 tumors) 53 (56 T) 52 (61T)
Complete necrosis (NS) 88% 92% 96%
Sessions More More Fewer (S)
1,2,3 OS (S) 85%, 61%, 50% 88%, 63%, 55% 90%, 82%, 74%
1,2,3 DFS (S) 61%, 42%, 17% 63%, 45%, 20% 78%, 59%, 37%
45 Ahmed Zeeneldin
46. PEI vs RFA
Cirrhosis, child A/B, 1-3 Tumors, 1.5-3 cm
RCT
Brunello et al, Scand J Gastroenterol. 2008;43(6):727-35.
Conventional PEI RFA
69 70
1-y CR (S) 36% 66%
HR OS (NS) 1 0.88
46 Ahmed Zeeneldin
47. PEI Vs RFA
Cirrhosis, child A/B, 1-3 Tumors, <= 3 cm
RCT
Shiina et al, Gastroenterology. 2005 Jul;129(1):122-30.
Conventional PEI RFA
114 118
Sessions (S) 6.4 2.1
4-y OS (S) 57% 74%
Recurrence/progression (S) higher Lower
47 Ahmed Zeeneldin
48. Resection Vs RFA
Cirrhosis, child A/B, solitary Tumors, <= 5 cm
RCT
Chen et al, Ann Surg. 2006;243:321-328.
Surgery resection RFA
90 71 (19 withdrew consent)
complications () More and severer
1,2,3,4-y OS (NS) 93.3%, 82.3%, 73.4%, 95.8%, 82.1%, 71.4%,
64.0% 67.9%
1,2,3,4-y DFS(NS) 85.9%, 69.3%, 64.1%, 86.6%, 76.8%, 69%,
46.4% 51.6%
48 Ahmed Zeeneldin
49. Ablation limitations
— Dome
— Capsule
— Near major blood vessel or bile duct or abdominal organ
49 Ahmed Zeeneldin
50. Embolization
— Aim: selective catheter-based infusion of particles targeted to the
arterial branch of the hepatic artery feeding the tumor leading to
ischemia. T:HA, NL: PV
— Types:
— bland embolization,
— chemoembolization
— radioembolization)
— Caution:
— arterial anatomy outlined
— embolization is limited to a segment, subsegment, or lobe
— Indications:
— All HCC tumors are embolizable if the arterial supply is isolated.
— Used in unresectable/inoperable tumors not amenable to ablation (>5cm),
alone or followed by ablation
50 Ahmed Zeeneldin
51. A celiac angiogram showing the blood vessels of the
liver with multiple HCC tumors before (left) and after
(right) treatment showing loss of vascularity and
response to therapy.
51 Ahmed Zeeneldin
52. Bland embolization (TAE)
chemoembolization (TACE)
— Particles to block arterial flow. :
— Gelatin sponge,
— polyvinyl alcohol, and
— polyacrylamide microspheres
— Chemotherapeutic agents:
— Doxorubicin and/or Cisplatin
— Containdications to TACE:
— Child C
— Portal v thrombosis
— Bilirubin > 3 mg/ml: liver abscess
— Biliary enteric bypass: liver abscess
52 Ahmed Zeeneldin
53. Bland embolization (TAE)
chemoembolization (TACE)
— Complications:
— acute portal vein thrombosis,
— cholecystitis, and
— bone marrow suppression,
— post-embolization syndrome
— fever,
— abdominal pain,
— and intestinal ileus
— Mortality: <5 %
53 Ahmed Zeeneldin
54. TAE Vs TACE Vs BSC
Unresectable HCC, Child A and B, Okuda I and II
RCT
HR of death for TACE vs BSC =0.47 (S)
Terminated early
TAE Vs TACE ??
Llovet et al, Lancet. 2002;359:1734-1739.
BSC TAE TACE
35 37 40
1,2-y OS (S) 63% and 27% 75% and 50% 82% and 63%*S
RR 34%
PortalV inasion Less
54 Ahmed Zeeneldin
55. TACE Vs BSC
Unresectable HCC,
RCT
TACE q 2-3 months
HR of death for TACE vs BSC =0.49 (S)
Lo et al, Hepatology. 2002;35:1164-1171.
BSC TACE (Cisplatin)
40 40
1,2, 3-y OS (S) 32, 11, 3% 57, 31, 26%
Death from liver failure more
55 Ahmed Zeeneldin
56. Radioembolization
— Agents:
— Microspheres embedded with yttrium-90 (beta radiation
emitter)
— tumor necrosis is more likely to be induced by radiation
rather than ischemia.
— PRR: 42%
— Complications:
— cholecystitis and
— abscess formation.
56 Ahmed Zeeneldin
57. Combinations of local therapies
TAE then RFA
— Aim: focused heat delivery of RFA may be enhanced by vessel
occlusion by TAE
— Use 3-5 cm tumors who are not eligible for liver resection or
transplantation
57 Ahmed Zeeneldin
58. TAE-> RFA Vs resection
Retrospective
1-3 lesions, size ,<= 3 cm, or single tumor ,<= 5cm
Child A, no vascular invasion, no mets,
Yamakado et al, Radiology. 2008;247:260-266
TAE/RFA Resection
104 62
1,2, 5-y OS (NS) 98%, 94%, 75% 97%, 93%, 81%
1,2, 5-y DFS (NS) 92%, 64%, 27% 89%, 69%, 26%
58 Ahmed Zeeneldin
59. TAE-> RFA/PEI Vs resection
Retrospective , single author experience
single tumor ,<= 7cm
Yamakado et al, Radiology. 2008;247:260-266
TAE/RFA/PEI Resection
33 40
1,2, 5-y OS (NS) 97%, 77%, 56% 81%, 70%, 58%
59 Ahmed Zeeneldin
60. Radiotherapy!!
— Conformal or stereotactic
— Focused, thus limiting the risk of radiation-induced liver
damage
— unresectable/inoperable due to performance status or
comorbidity e.g. if PEI, RFA, TACE, TAE is not feasible
60 Ahmed Zeeneldin
73. COST
— One box(m)$ 5000 = 5000 x 5.5 = 27,500 LE
— Duration of therapy
— Until no longer clinically benefiting from therapy
or until unacceptable toxicity occurs
— For OS of 10.7 m:
— 10.7 x 27, 500= 294, 250
— For PFS of 5.5 m
— 5.5 x 27, 500= 151, 250
73 Ahmed Zeeneldin
74. Sharp trial summary
Sorafinib BSC
MOS (S) 10.7 m 7.9 m
TTP (S) 5.5 m 2.8 m
Toxicity Hand-foot
diarrhea
Cost 150-294, 000 LE
Child A >90% *
PS 0-1 >90%*
74 Ahmed Zeeneldin
75. Asia-Pacific Sorafinib trial
Sorafinib BSC
150 76
MOS (S) 6.2 m 4.1 m
MTTP (S) 2.8m 1.4 m
Child A >97% *
PS 0-1 >90%*
Cheng et al., J Clin Oncol 26: 2008 (May 20 suppl; abstr 4509)
75 Ahmed Zeeneldin
76. Take home message
— Risk factors for HCC
— Screen high-risk subjects by US and AFP
— Classic appearance in CT, MRI, tri-US: arterial uptake and
venous washout
— Liver function assessment and reserve
— Patient, liver, tumor
— Surgery: resection and transplant
— Local regional therapy: ablation, emobolization
— Systemic therapy = sorafinib
76 Ahmed Zeeneldin