PPT2

1. HEPATOCELLULAR
CARCINOMA
WE CAN CHANGE THE OUTCOME

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

5. Investigations
 Hb – 6.6 gm % - transfused 2 PRC’s.
 PS –Normocytic hypochromic aneamia
 Platelets-3.2 lakhs
 INR-1.21
 LFT bil-1.2,alb 3.3 OT/PT-56/67
 Iron , B12 low
 Viral markers negative
 Echo, ECG - normal

6. Investigations
 UGI scopy – normal study of stomach
 Colonoscopy – small Haemorrhoids. Occasional
uncomplicated left colonic diverticulae +
 CT abdomen – for evaluation of bleeding

7. NON CONTRAST CT

8. CT : ARTERIAL PHASE

9. CT: PORTAL VENOUS PHASE

10. CT: EQUILIBRIUM PHASE

12. DDs for liver SOL
 Can you characterise liver lesions on imaging?

13. IMAGING OF HEPATOMAS
USG, CT, MRI

14. ULTRASONOGRAPHY IN HEPATOMA

15. CT OF HEPATOMA

16. VALUE OF MRI IN HEPATOMA
SIDEROTIC NODULE – appears black
Dyplastic nodule:
NO ARTERIAL PHASE ENHANCEMENT
HEPATOMA: ARTERIAL PHASE ENHANCEMENT

17. Differentiation from other solid liver lesions
Focal Nodular Hyperplasia

18. HepaticAdenoma
Sub capsular feeding artery
Thin capsule with delayed enhancement.

19. Hemangioma

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

23. Treatment Options for HCC
Surgical Resection
Open
Laparoscopic
Liver Transplantation
Local Ablative Therapies
RFA
PEI
Microwave etc
Regional Therapy
Multimodality therapy
TACE
Theraspheres
Hepatic arterial infusion
Systemic chemotherapy
Radiation therapy
Cyberknife

24. Treatment of HCC

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

26. What resection and how much to
resect

30. HCC- Child’s A Cirrhosis

31. Radiological Assessment?
 Virtual Surgery
 Volumetry of the Liver to assess for
residual liver or future liver remnant (FLR)

32. HOW CAN TECHNOLOGY
HELP ?
ADVANCED CT IMAGING TECHNIQUES.

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

37. Armamentarium

39. Right post sectionectomy for this
patient

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.

42. Microscopy
MICROACINAR
PATTERN
HYALINE GLOBULES WITH POORLY
DIFFERENTIATED CELLS

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

49. THANK YOU