HEPATOCELLULAR HEPATOCELLULAR CARCINOMACARCINOMA

MontonMonton

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

HCC in ThailandHCC in Thailand

• 60-90% associated with cirrhosis

• Risk factor– HBV 35-85%– HCV 18.6%– Alcohol ~10%– etc. aflatoxin

Multisteps carcinogenesis

INITIATION

PHASE

PROMOTION PHASE

CIRRHOSIS

HBV HBC

AFLATOXIN

ALCOHOL

Cause of death Cause of death

• Hepatic failure 39-45%

• GI bleeding 13.8-23.3%

• Cancer death 10%

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

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

TreatmentTreatment

• Curative– Surgery– Liver transplantation– Percutaneous : PEI,RFA

• Palliative– TACE– Hormone– Systemic chemotherapy

SurgerySurgery

• First choice in non-cirrhotic pt

• 5yr survival ~ 50%

• High recurrent rate : 50% in 3yr• Suspect undetected micrometastasis

• 4,000-10,000 baht

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

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

TACETACE

• Transarterial chemoembolization

• Palliative treatment

• Principle – Cytotoxic agent(doxorubicin/cis) + lipiodol– Embolization

• Improvement in 2yr survival

• 10,000 – 30,000 baht

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

Systemic therapySystemic therapy

• Hormonal rx– not improve survival

• Systemic chemotherapy– not improve survival compared with best

supportive care

Future trendsFuture trends

• Antiangiogenic agent– Vascular endothelial growth factor inhibitor

• Immunotherapy– Tumor specific effector T-cell

• Gene therapy – Intratumoral immunomodulatory cytokine

ProblemProblem

• Most patients are unresectable

• High recurrent rate after surgery

• Cannot detect micrometastasis

• Early detection of HCC is appropriate

HCC surveilanceHCC surveilance

• Focus on cirrhotic patients

• Tumor doubling time ~ 6 mo

• Tools are1. AFP

2. Ultrasonography

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

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

USGUSG

• Sensitivity

USG 79.4

CT 87.6

MRI 88.9

Yao et al,J Hepatol,2001

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

Thank youThank you