Download - Grish hcc presentation
HEPATOCELLULAR
CARCINOMAWE CAN CHANGE THE OUTCOME
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
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
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
Investigations
UGI scopy – normal study of stomach
Colonoscopy – small Haemorrhoids. Occasional
uncomplicated left colonic diverticulae +
CT abdomen – for evaluation of bleeding
NON CONTRAST CT
CT : ARTERIAL PHASE
CT: PORTAL VENOUS PHASE
CT: EQUILIBRIUM PHASE
DDs for liver SOL
Can you characterise liver lesions on imaging?
IMAGING OF HEPATOMAS
USG, CT, MRI
ULTRASONOGRAPHY IN HEPATOMA
CT OF HEPATOMA
VALUE OF MRI IN HEPATOMASIDEROTIC NODULE – appears black
Dyplastic nodule:
NO ARTERIAL PHASE ENHANCEMENT
HEPATOMA: ARTERIAL PHASE ENHANCEMENT
Differentiation from other solid liver lesions
Focal Nodular Hyperplasia
HepaticAdenoma
Sub capsular feeding artery
Thin capsule with delayed enhancement.
Hemangioma
Further Evaluation ?
Tumour markers
AFP – 423 IU/dl
DCP/CEA/CA 19 9 - normal
?Biopsy
Decision on curative treatment
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
How to manage this case ?
Diagnosis conformed by Imaging and AFP
Treatment Options for HCC
Surgical ResectionOpenLaparoscopic
Liver Transplantation
Local Ablative TherapiesRFAPEIMicrowave etc
Regional TherapyTACETheraspheres
Hepatic arterial infusion
Systemic chemotherapyRadiation therapyCyberknife
Multimodality therapy
Treatment of HCC
Performance statusAssociated Medical Diseases
Stage of DiseaseSize /Number of lesions
Extrahepatic diseasePortal vein status
Functional hepatic reserve
Which patients should undergo resection?
What resection and how much to
resect
HCC- Child’s A Cirrhosis
Radiological Assessment?
Virtual Surgery
Volumetry of the Liver to assess for
residual liver or future liver remnant (FLR)
HOW CAN TECHNOLOGY
HELP ?
ADVANCED CT IMAGING TECHNIQUES.
TOTAL LIVER VOLUME: 1256 CC
RESIDUAL LIVER VOLUME: 1256-
440CC = 816CC
PERCENTAGE
RESIDUAL LIVER
VOLUME = 64%
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%
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
Armamentarium
Right post sectionectomy for this
patient
Post operative Course
No major morbidity
Discharged on Day 6
Follow up- doing well
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.
Microscopy
MICROACINAR PATTERN
HYALINE GLOBULES WITH POORLY
DIFFERENTIATED CELLS
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
Pathology of HCC
Histopathology of this patient
Prognostic factors
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.
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
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
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
THANK YOU