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HEPATOCELLULAR HEPATOCELLULAR CARCINOMACARCINOMA
MontonMonton
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HCC in ThailandHCC in Thailand
• Most common cancer in Thai male
• Incidence 5 x 100,000 / year
• Male : female = 3-8:1
• Age > 40 yr
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HCC in ThailandHCC in Thailand
• 60-90% associated with cirrhosis
• Risk factor– HBV 35-85%– HCV 18.6%– Alcohol ~10%– etc. aflatoxin
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Multisteps carcinogenesis
INITIATION
PHASE
PROMOTION PHASE
CIRRHOSIS
HBV HBC
AFLATOXIN
ALCOHOL
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Cause of death Cause of death
• Hepatic failure 39-45%
• GI bleeding 13.8-23.3%
• Cancer death 10%
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Diagnostic criteriaDiagnostic criteriaEASL conference 2000EASL conference 2000
• Cyto-histological criteria• Non-invasive criteria(cirrhosis)
1.Radiological criteria : 2 imaging
- focal mass > 2 cm
- 1 imaging show hypervascularization
2.Combined criteria
- 1 imaging mass >2cm,hypervascularization
- AFP > 400 ng/ml
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StagingStaging
• No standard staging system
• Most system focus on1.performance status
2.tumor characteristics
intrahepatic and extrahepatic
3.liver function
• French,CLIP,BCLC,CUPI,TNM
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TreatmentTreatment
• Curative– Surgery– Liver transplantation– Percutaneous : PEI,RFA
• Palliative– TACE– Hormone– Systemic chemotherapy
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SurgerySurgery
• First choice in non-cirrhotic pt
• 5yr survival ~ 50%
• High recurrent rate : 50% in 3yr• Suspect undetected micrometastasis
• 4,000-10,000 baht
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Liver transplantationLiver transplantation
• Cure underlying cirrhosis
• 5yr survival ~ 70%
• Milan criteria• 1 mass , < 5 cm • 3 mass , < 3 cm
• Less available
• Long term immunosuppression
• 300,000 – 500,000 Baht
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PercutaneousPercutaneous
• Alternative in unresectable tumor
• No destruction to non-tumor tissue
• Can do in cirrhosis
• Tumor seeding is problem
• PEI : percutaneous ethanol injection– 2,000 baht
• RFA : radiofrequency ablation– 40,000 baht
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TACETACE
• Transarterial chemoembolization
• Palliative treatment
• Principle – Cytotoxic agent(doxorubicin/cis) + lipiodol– Embolization
• Improvement in 2yr survival
• 10,000 – 30,000 baht
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ContraindicationContraindication of TACEof TACE
• Decompensated cirrhosis
particularly bilirubin > 2 mg/dl
• Encephalopathy
• Reverse or absent portal flow
• Tumor burden > 50% of liver
• Renal failure
• Active infection
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Systemic therapySystemic therapy
• Hormonal rx– not improve survival
• Systemic chemotherapy– not improve survival compared with best
supportive care
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Future trendsFuture trends
• Antiangiogenic agent– Vascular endothelial growth factor inhibitor
• Immunotherapy– Tumor specific effector T-cell
• Gene therapy – Intratumoral immunomodulatory cytokine
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ProblemProblem
• Most patients are unresectable
• High recurrent rate after surgery
• Cannot detect micrometastasis
• Early detection of HCC is appropriate
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HCC surveilanceHCC surveilance
• Focus on cirrhotic patients
• Tumor doubling time ~ 6 mo
• Tools are1. AFP
2. Ultrasonography
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AFPAFP
• Produced from – Fetal liver cell– Yolk sac
• Normal range 10-20 ng/ml• AFP increases in
– exacerbation of chronic viral hepatitis (20-250 ng/ml)
– Germ cell tumor
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AFP cut-offAFP cut-off
Cut-off sens spec NPV PPV
20 60 89.4 97.7 25.1
200 22.4 99.4
400 17.1 99.4
Trevisani et al,J Hepatol,2001
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USGUSG
• Sensitivity
USG 79.4
CT 87.6
MRI 88.9
Yao et al,J Hepatol,2001
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Surviellance & recall strategySurviellance & recall strategy USG/AFP q 6mo
liver nodule no nodule
1-2cm >2cm <1cm AFP^ AFP-
FNAB AFP>400 USG/3mo spiralCT imaging
no HCC
HCC
surveillance/6mo Bruix J et al. J Hepatol,2001Bruix J et al. J Hepatol,2001
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Thank youThank you