The document discusses the anatomy of the liver, particularly the Couinaud classification that segments the liver into eight functional units. It addresses the increasing incidence of hepatocellular carcinoma (HCC), its risk factors, clinical presentations, diagnostic methods, staging systems, and treatment strategies. Emphasis is placed on prevention through managing viral hepatitis and lifestyle changes to mitigate the risk of liver cancer.

1. Presented by:
Dr. Aleena Bhari
Dr.Kawshik Ahmed
Intern doctors, Surgery department
Enam medical college and 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 its own dual vascular
inflow,biliary drainage and lymphatic drainage.
• In general each segment is wedge shaped with apex directed
towards hepatic hilium(porta hepatis)
• Segment 1 is caudate lobe lies posterior around IVC
• Segment 1-5 makeup left hemiliver and remaining right .
• For liver to remain viable, resection occur along hepatic veins and
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 by day due to -chronic
hepatitis B &C virus infection.
 -cirrhosis due to any cause.
 The disease is more common in male(4:1)usually in
middle age 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
• Wilson disease

11. Pathogenesis
 The exact pathogenesis is unknown.
 The disease seems to occur in stages:
Chronic liver injury > cell death >regeneration>
cellular metabolic dysfunction> 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 –incase of metastasis.

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

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

15. SPREAD
Tend to spread by invasion into vasculature
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 or core biopsy

18. Images of investigation

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

20. Contd..

21. MRI Studies Showing the Effects of Hepatocellular Carcinoma at
Different Stages of the Disease.
El-Serag HB. N Engl J Med 2011;365:1118-1127
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: Early asymptomatic curable.
 Methods: AFP (every 6 month) & Ultrasound
 Indications: For patient at risk for HCC:-
-Cirrhosis
-Hepatitis B,C
-Alcohol consumption
-Genetic hemachromatosis
-Autoimmune hepatitis
-Non alcoholic steatohepatitis
-Primary biliary cirrhosis
-Alpha1 antitrypsin deficiency

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

32. A. Surgical approach
a. Segmental or local resection
b. Lobectomy or partial hepatectomy
c. Extended lobectomy
d. Liver transplantation

33. Contd..
First 3 for: Liver transplantation
for:
Single tumor within
single segment
Child Turcotte Stage A
Tumor size <5 cm
Multiple tumor size of
each <3cm
Single tumor size<5cm
Multiple tumor sizeof
each<3cm
No vascular invasion
No extrahepatic spread

34. Images of surgical treatment

35. B.Nonsurgical therapy
Majority of HCC not be amenable to surgical
resection because of :-
=Advanced stage of the carcinoma &
=Severity of the underlying liver disease

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

37. Radiofrequency ablation

38. Transarterial chemo embolization

39. Prognosis after treatment:
o5 year survival rate:- 30-40% after liver
resection
o5year survival rate:- 75% in liver
transplantation
o2 year survival 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.