13 liver cancer
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Department of Hepatobiliary Oncology,SYSUCC
Anti-liver cancer team
Shengping Li, M.D., Ph.D
•Advanced stage
•Low resection rate
•High recurrence
•Decompensation liver function
Poor prognosisFierce
Liver cancer
PLC (Primary Liver Cacner)
Secondary Liver Cancer
HCC(Hepatocellular carcinoma)
CCC(Cholangiocellular carcinoma)
HCC
HCC and CCC mixed
Epidemiology
“Hot spots” – 150 per 100 000
US, Australia : 2 per 100 000
•The fifth most common
cancer worldwide
•CA Cancer J Clin 2005
High incidence In China
• Shanghai
• Jiangsu
• Fujiang
• Guangdong
• Guangxi
Epidemiology
Trend of Death rate of malignant Trend of Death rate of malignant tumor in China tumor in China
LungLiverStomach
1282004-2005
StomachLiverLung
1061990-1992
Stomach EsophagusLiver
801973-1974
Three leading causes of Ca. death
Death Rate(per100,000)
Period(years)
EtiologyEtiology
Hepatitis
Alcoholism
Environmental factors
molecular and Cytogenetic alterations
HBV 80% (Asia and Africa),
100 million china
HCV 70% (Japan,West count
ries)
Hepatitis virus infectionHepatitis virus infection
Alcoholism: alcoholic cirrhosis
Food contaminated with aflatoxin
Decayed peanut,corn
Turkey Liver cancer
Liver Flukes (Clonorchis sinensis )
Liver Flukes InfestationLiver Flukes Infestation
Mutation of oncogene and tu
mor suppressor gene
(癌基因和抑癌基因的突变) N-ras,c-myc,cfms,CSF-1R, IGF
-II , p53 , TTR, DLC-1, LPTS, W
FDC1, HCCS1, HCRP1, 17HSDB2
Chromosomal alterations
( 染色体改变)
Gain (获得) :1q,8q and 20q
Lose (缺失) : 4q,8p,13q,16q
,
and 17p
( Li SP, et al . J Hepatology 2001)
Molecular and cytogenetic aberration
(分子和细胞遗传学变异)
Peoples lived in high incidence of liver cancer area
Peoples persistent infection of hepatitis virus
Family history of liver cancer
Liver cancer history previously
High Risk Group
Early stage Subclinical stage
Non symptom and sign
Clinical manifestation
• Abdominal pain and distention
• Weight loss
• Hepatomegaly : 80%
• Abdominal mass
• Jaundice ,ascites
Clinical stage
Diagnosis of HCCDiagnosis of HCC
Serological (tumor markers)
Radiological
Cytological
Histological
Either alone or in combination
Tumor markers for HCCTumor markers for HCCMost common used
Diagnostic Imaging for Diagnostic Imaging for HCCHCC
Radiology--USRadiology--US
Ultrasound– Availability, cost– Operator
dependant– Therapeutic role.
Radiology--CTRadiology--CT
Triphasic CT – detect 30 – 40%
more tumour nodules than conventional CT.
Lipiodol – Retained by all
hypervascular liver tumours.
Radiology--MRIRadiology--MRI
Slightly higher sensitivity than CT in detecting hepatic lesions.
Cost, availability.
Diagnosis and treatment simultaneously
Invasive, not routinely used
Radiology--angiographRadiology--angiograph
• Expensive
• Whole body sca
ning
• Tumor cell Funct
ion
Radiology--Positron Emission computed Tomography, PET/CT
Liver BiopsyLiver Biopsy
Biopsy now rarely required to diagnose HCC.
Avoid biopsy of potentially resectable tumour.– Risk of needle track seeding 1 – 3%– Risk of bleeding
US and CT most commonly used clinically
Diagnostic imaging for Diagnostic imaging for HCCHCC
1. AFP≥400 ng/L, palpable mass or space-occupying
lesions in the liver by imaging
2. AFP<400 ng/ L, specific liver cancer images confir
med by at least two kinds of imaging scanning
3. Clinical manifestation of liver cancer with patholog
ical diagnosed extrahepatic liver cancer and meta
stases liver tumor ruled out
Standard rule for Diagnosis of HCC
Clinical Application of Clinical Application of AFPAFP
1.Screening of liver cancer
2.Dianosis of liver cancer
3.Predicting prognosis after treatment
4.Surveillance of recurrence after
treatment( decrease to normal level
within 1-2 months after resection)
Differential diagnosisDifferential diagnosis
AFP positive
chronic active hepatitis, cirrhosis, testicular tumor,
pregnancy
AFP negative
haemangioma, metastatic liver carcinoma, absces
s, focal nodular hyperplasia (FNH), hepatic hydatid
osis
Pregnancy with HCC
Delivery baby and resection of HCC simultaneously
Hepatic haemangioma
Colon cancer liver Colon cancer liver metastasismetastasis
Focal Nodular Hyperplasia Focal Nodular Hyperplasia (FNH)(FNH)
Hepatic AbscessHepatic Abscess
Hepatic Hepatic HydatidosisHydatidosis
Therapeutic Option for Therapeutic Option for HCCHCC
SurgerySurgery
Langenbuch 1888 first left hepatic
lobectomy Tiffany 1890
first liver resection for solid tumour
Starzl 1963 first liver
graft
Principles of Surgical Principles of Surgical ManagementManagement
Determining resectability
Stage of tumour
Functional hepatic reserve
80%-90% of HCC occur in cirrhotic livers
Less than 20% of patients with HCC are candidates for resection at time of presentation.
1. Staging1. Staging
TNM– Stage III, IV unresectable
Okuda CLIP (Cancer of the Liver Italian Program) Barcelona Staging Classification
– Performance scores, Okuda, tumour morphology
French Staging Classification– Performance scores, LFT, US
TNM Staging System
stagingstaging
Because the combined impact of liver diseaseand tumor burden is not yet fully understood, andthe cause of HCC may vary geographically, noneof the currently used staging systems fulfils all therequirements for stratification of patients with HCCinto groups of different prognosis and therapeuticrecommendations. None of the staging systems isuniversally accepted.
2. Functional Reserve2. Functional Reserve
Resection only of benefit in patients with adequate functional reserve.
Assessment of liver function : – Synthetic capacity of liver
» Serum albumin, prothormbin time
– Excretion of metabolites» Indocyanine dye test, bilirubin, bile acid profile
– Child-Pugh Classification
Child Pugh ClassificationChild Pugh Classification
2. Functional Reserve2. Functional Reserve
Portal hypertension Estimation of likely remaining liver
volume after resection Comorbidities
– ASA / Performance scores– Nutritional state : Perioperative
nutritional support decreases post operative morbidity
5-year survival 26-50%, mean 30%
5 years recurrence rate is about 70%
A critical clinical problem
Hepatectomy
6 mPre-op
Cutting edge recurrence
Liver transplantationLiver transplantation
• Potentially resect HCC while replacing the cirrhotic liver
• Milan criteria for HCC
Single lesion <5cm or upto three lesions <3cm
LimitationLimitation
Immunosuppression– Recurrent hepatitis– Recurrent HCC
Shortage of donors – Consider “bridging therapy” to
prevent tumour progression.– Living donors
Non Surgical Management Non Surgical Management Transcatheter Arterial Chemoembolization Percutaneous microwave coagulation therapy Percutaneous ethanol injection Radiofrequency Ablation Cryosurgery Systemic Chemotherapy Hormonal therapy Immunotherapy Gene Therapy Chinese medicine
Percutanous interventiPercutanous interventiononPEI: percutanous ethanol injection
RF: Radiofrequency ablation
MCT: microwave coagulation thermotherapy
LT: Laser thermotherapy
Cryoablation
Best option for small unresectable HCC
将 10枚象“弹头”一样的小电极通过穿刺针管送入癌组织,多枚小电极从不同的角度和方向“锁定”癌症组织区域,由计算机测算出射频治疗所需的最佳温度,时间,功率和阻抗,由小电极发出高能射频波,在 100
—120℃的高温下,使癌组织蛋白发生凝固性坏死,达到杀灭癌组织的效果。
3.5cm/15G 10 electrodes Lee Veen needle
Radiafrequency ablation,RF•Alternative to PEI
•Applied percutaneously,laparoscopically, during laparotomy
•Expensive but offer a better local control
•Ablation of tumor large than 5 cm in diameter
• The most widely used treatments for HCCs which
are unresectable or cannot be effectively treated with
percutaneous interventions.
•Embolization agents: Lipiodol,gelfoam
•Chemotherapeutics: doxorubicin, 5-Fu, mitomycin, cisplatin
•Partial responses in 15-55% of patients
• Delays tumor progression and vascular invasion
•Prolongs the survival time compared to conservative management.
TACE or TAE
TACE or TAE
•Patients liver function Child A
•Without vascular invasion or extrahepatic spread.
•Advanced liver disease (Child B or C), treatment-induced liver failure may offset the antitumor effect or survival benefit of the intervention.
•Postoperative adjuvant TACE may improve survival in patients with risk factors for residual tumor
Tumor shrinkage post-TACE
Principles of
management •Treatment in early stage
•Combination therapy
•Actively( time and again)
Metastasis of HCC
Intrahepatic ---port vein pathway, satellite
Extrahepatic: lung Lymphatic pathway: CCC Invasion periheaptic organs directly Abdominal implantation: tumor rupture
HCC metastasis
Continuing challenges
•Prevalance of chronic hepatitis
•Low resection rate
•High recurrence rate post-resection
•Shortage of liver donor
•Optimal combination therapy
•Molecular staging system
Thank you!Thank you!
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