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Basics of Hepatocellular cancer management for surgeons
- 1. 23 years 11 years 6 years
- 2. Dr. Ilango S. MS, MCh (SGE), FASTS (Multi organ Transplant) Director, Liver and pancreas Cancer Unit Pancreas Cancer Research and Referral Clinic. Chennai drsilango@gmail.com
- 3. Myths, facts and the right choice of treatment
- 4. What is the survival? 5 year survival
- 5. Easiest method to decide which patient benefits treatment
- 7. Viral markers Imaging Liver function tests Tumor markers HBV, HCV Triphasic CT scan Is the surrounding liver good?
- 8. Sequential: Plain, arterial, venous phases in HCC CT scan Sequential: Plain, arterial, venous phases in Hemangioma CT scan LIRAD type 4,5 Arterial enhancement, venous wash out The specific CT scan that must be ordered is a Triphasic CT scan
- 11. MRI in HCC: Look at the non contrastT2W images.White lesions inT2W images are significant lesions. Enhancement is checked inT1W images MRI in Hemangioma
- 13. White appearance in T2 W Plain MRI is a significant finding. This requires specialist opinion.
- 17. Resection Transplant PEI/RFA/RTx TACE Therasphere New Agents Symptomatic Tx HCC Stage A PST 0, CTP A, Okuda 1 Very early Single < 2 cm Portal Press/Bili Normal 3 nodules < 3 cm Associated disease increased no yes Stage B,C,D PST 0-2, CTP A-B, Okuda 1-2 Early stage B Single < 5 cm, PST 0 Intermediate stage C Multi-nodules, PST 0 CTP A CTP B Decreasing a-FP Advanced Stage D Portal Vein invasion, N1,M1, PST 1-2 Portal vein invasion, N1, M1 No Yes Stage E PST>2,CTP C,Okuda 3 Terminal Stage D
- 18. HCC ECOG < 2, NormalADL ECOG > 2, No self care, End stage organ failure Resection Transplant PEI/RFA TACE TARE Symptomatic Tx CTPA, B6 Normal portal pressures Bili < 2 CTP B 7 - C Increased portal pressures Bili > 3 FLR > 30% Within UCSF criteria Yes No Yes No PVE Within UCSF criteria, but size < 3 cm N1, M1+ ECOG < 2 Sorafenib MITTR Protocol HCC 2016
- 23. What if your biopsy shows normal hepatocytes? Always look for portal triads under low power. No lobular architecture = Hepatic adenoma Check for reticulin loss = well differentiated HCC
- 24. What size of tumour can you remove? Any size
- 26. 1.25kg; measuring 17 x 16 x 10 cm
- 30. Facts that are important Facts that are not important
- 31. Size is a surrogate marker of vascular invasion Look for invasion of a muscular wall vessel 1 cm beyond the tumor
- 33. HCC ECOG < 2, NormalADL ECOG > 2, No self care, End stage organ failure Resection Transplant PEI/RFA TACE TARE Symptomatic Tx CTPA, B6 Normal portal pressures Bili < 2 CTP B 7 - C Increased portal pressures Bili > 3 FLR > 30% Within UCSF criteria Yes No Yes No PVE Within UCSF criteria, but size < 3 cm N1, M1+ ECOG < 2 Sorafenib MITTR Protocol HCC 2016
- 40. 1.05 kg; measuring 20 x 16.5 x 5 cm
- 45. Schwartz, Liver Transplantation for Hepatocellular Carcinoma, Gastroenterology. 2004: 127 S268-276.
- 46. Schwartz, Liver Transplantation for Hepatocellular Carcinoma, Gastroenterology. 2004: 127 S268-276.
- 47. Yoo et al. Journal of Clinical Oncology. 2003: 21 4329-4335.
- 48. Mazzaferro, et.al. NEJM1996;334:693-699 Yao et al. Liver transplantation for hepatocellular carcinoma: expansion of the tumor size limits does not adversely impact survival. Hepatology. 2001 33:1394
- 49. Regalia et al. Liver Transplantation for small hepatocellular carcinoma in cirrhosis: analysis of our experience. Transplantation Proceedings, 33, 1442–1444 (2001)
- 50. Yao et al. Liver Transplantation. 2002: 8(9) 765-774
- 51. Schwartz, Liver Transplantation for Hepatocellular Carcinoma, Gastroenterology. 2004: 127 S268-276.
- 52. Schwartz et al. Adult living donor liver transplantation for patients with hepatocellular carcinoma. Annals of Surgery2004:239(2) 142-9 Lo et al. The role and limitations of living donor liver transplantation for hepatocellular carcinoma. Liver Transplantation. 2004;10:440-7
- 53. Kulik and Abecassis. Living donor liver transplantation for hepatocellular carcinoma. Gastroenterology. 2004;127:S277. Axelrod et al. Living donor liver transplant for malignancy. Transplantation. 2005;79(3):363-6
- 54. A2ALL Study Group. A comparison of adult iving donor (LDLT) to deceased donor liver transplant (DDLT) for hepatocellular carcinoma: data from the A2ALL study. Hepatology. 2005;42(4) 199a (AASLD abstract) Wong et al. Living donor versus deceased donor liver transplantation for early irresectable hepatocellular carcinoma. British Journal of Surgery 1007; 94:78-86.
- 55. Better patient selection!! Better criteria for transplantation Better surrogates for vascular invasion
- 56. Resection Transplant PEI/RFA/RTx TACE Therasphere New Agents Symptomatic Tx HCC Stage A PST 0, CTP A, Okuda 1 Very early Single < 2 cm Portal Press/Bili Normal 3 nodules < 3 cm Associated disease increased no yes Stage B,C,D PST 0-2, CTP A-B, Okuda 1-2 Early stage B Single < 5 cm, PST 0 Intermediate stage C Multi-nodules, PST 0 CTP A CTP B Decreasing a-FP Advanced Stage D Portal Vein invasion, N1,M1, PST 1-2 Portal vein invasion, N1, M1 No Yes Stage E PST>2,CTP C,Okuda 3 Terminal Stage D
- 57. HCC ECOG < 2, NormalADL ECOG > 2, No self care, End stage organ failure Resection Transplant PEI/RFA TACE Therasphere Symptomatic Tx CTPA, B6 Normal portal pressures Bili < 2 CTP B 7 - C Increased portal pressures Bili > 3 FLR > 30% Within UCSF criteria Yes No Yes No PVE Within UCSF criteria, but size < 3 cm N1, M1 Sorafenib MITTR Protocol HCC 2016
- 58. New mass in the liver always needs aVILT work up. Never believe a diagnosis of hemangioma. Use all resources to predict biology. Attempt curative treatments as much as possible. 5 year survival of 70% is good. Use simplified algorithms for decision making.