Hepatocellular carcinoma related to Hbv and Hcv

Hepatocellular carcinoma is the 5th most common malignancy worldwide with male-to-female ratio

– 5:1 in Asia– 2:1 in the United States

Tumor incidence varies significantly, depending on geographical location.

HCC with age. – 53 years in Asia– 67 years in the United States.

Incidence according to etiology

Etiology•Hepatitis B

-increase risk 100 -200 fold

•Hepatitis C•Cirrhosis

- 70% of HCC arise on top of cirrhosis

•Toxins -Alcohol -Tobacco - Aflatoxins

•Autoimmune hepatitis•States of insulin resistance- Overweight in males Diabetes mellitus

Signs & symptoms Nonspecific symptoms

– abdominal pain– Fever, chills– anorexia, weight loss– jaundice

Physical findings– abdominal mass in one third– splenomegaly– ascites– abdominal tenderness

which patients are at high risk for the development of HCC & should be offered surveillance

- M &F with established cirrhosis due to HBV and/ or HCV, particularly those with ongoing viral replication

- M &F with established cirrhosis due to genetic haemochromatosis

- M with alcohol related cirrhosis

- M with primary biliary cirrhosis

Patient who require surveilanceAsian men > 40 y (HBV chronic hepatitis)Asian women> 50 yFamily history of HccCirrhotic patientAfrican and and north American black

Screaning Patient with hbv who are African appear to

get hcc at a younger age

Risk factor for hbvHost

Male ( estrogen and testosterone )Family history of hccCirrhosisobesity

virusElevated hbv DNA levelHbe AgGenotype C and D HDV , HIV , or HCV co-infection

Environmental AlcoholTobacco ( smoking)Aflatoxin B

Because hcc may develop in chronic hbv in the absence of cirrhosis , many patients may have had preserved liver function and thus been able to tolerate resection.

hccGenotype 1bHCV RNA level

diagnosisUltra sonography AFP

End stage of cirrhosis(prognosis)

Treatment/Managmenttement

Treatment (Surgery)The only proven potentially curative therapy

for HCC Hepatic resection or liver transplantation

Patients with single small HCC (≤5 cm) or up to three lesions ≤3 cm

Resection Hepatic resection should be considered in HCC and

a non-cirrhotic liver (including fibrolamellar variant)

Resection can be carried out in highly selected patients with cirrhosis and well preserved hepatic function (Child-Pugh A) who are unsuitable for liver transplantation. It carries a high risk of postoperative decompensation.

The majority of early mortality is due to liver failure.

Transplantation

Liver transplantation should be considered in any patient with cirrhosis

Transplantation Milan Criteria : Single HCC ≤5 cm or Up to three nodules ≤3 cm No extra hepatic spread About 10 % qualify for listing The major drawback of transplantation is

The scarcity of donors. The long waiting time.

Treatment (non-Surgical)should only be used where surgical therapy is not

possible.

1) Percutaneous ethanol injection (PEI) has been shown to produce necrosis of small HCC. It is best suited to peripheral lesions, less than 3 cm in

diameter

2) Radiofrequency ablation (RFA) High frequency ultrasound to generate heat good alternative ablative therapy No survival advantage Useful for tumor control in patients awaiting liver

transplant

Treatment (non-Surgical3) Cryotherapy

intraoperatively to ablate small solitary tumors outside a planned resection in patients with bilobar disease

4) Chemoembolisation

Concurrent administration of hepatic arterial chemotherapy (doxirubicin) with embolization of hepatic artery

Produce tumour necrosis in 50% of patients Effective therapy for pain or bleeding from HCC Affect survival in highly selected patients with good

liver reserve Complications: (pain, fever and hepatic

decompensation)

Treatment (non-Surgical5) Systemic chemotherapy

very limited role in the treatment of HCC with poor response rate

Best single agent is doxorubicin (RR: 10- 20%) should only be offered in the context of clinical trials

6) Hormonal therapy- Nolvadex, stilbestrol and flutamide

7) Interferon-alfa8) retinoids and adaptive immunotherapy (adjuvant)

Radiofrequency Ablation

Transarterial ChemoembolizationMeta-analysis of 7 randomized controlled trials • 2 yr survival: 41% (19-63%)• Treatment response: 35% (16-61%) • Average no. of sessions: 1-4.5 • Risks:

– Infection – Tumor lysis syndrome – Hepatic failure