Hepatocellular Carcinoma Diagnostic and Therapeutic Strategies - PowerPoint PPT Presentation

1 / 28
About This Presentation
Title:

Hepatocellular Carcinoma Diagnostic and Therapeutic Strategies

Description:

Title: Hepatocellular Carcinoma Description: Dr. F. Sanai Last modified by: Me Created Date: 1/19/2003 6:29:25 AM Document presentation format – PowerPoint PPT presentation

Number of Views:202
Avg rating:3.0/5.0
Slides: 29
Provided by: rmhiamsCo
Category:

less

Transcript and Presenter's Notes

Title: Hepatocellular Carcinoma Diagnostic and Therapeutic Strategies


1
Hepatocellular CarcinomaDiagnostic and
Therapeutic Strategies
  • Faisal Sanai
  • Consultant Hepatologist
  • Riyadh Military Hospital

10th International Advanced Medicine Symposium
2
Tumor Markers for HCC
  • ?-l-Fucosidase.
  • 5- nucleotide phosphodiesterase.
  • Des3 ? carboxy prothrombin.
  • CA 19-9, CA 125, ALP.
  • Alpha Fetoprotein.
  • Fucosylated AFP.

3
Alpha FetoproteinSensitivity and Specificity
Issues
  • GI tumors 10 20.
  • Cirrhosis 40.
  • Acute and chronic hepatitis 20.
  • Pregnancy.
  • Gonadal tumors 80.
  • Ethnicity.
  • Etiology of liver disease.
  • Treatment of underlying liver disease.
  • Tumor staging.

Sensitivity patterns for HCC vary widely 32
93 Colli A, et al. Am J Gastro 2006.
4
Alpha FetoproteinChange in HCC Detection by
Changing Cut-off Points
Diagnostic Criteria Sensitivity () Specificity ()
gt615 ng/ml 56.4 96.4
gt445 ng/ml 56.4 94.5
gt100 ng/ml 72.6 70.9
gt20 ng/ml 87.1 30.9
Poon TCW, Clin Liv Dis 2001
5
Diagnostic Yield of U/S
  • Sensitivity in cirrhotic liver 60.
  • Specificity 97.
  • Colli A, et al. Am J Gastro 2006
  • Sensitivity for lesions 1 - 2 cm 13.
  • Sensitivity for lesions 2 - 3 cm 20.
  • Dodd G, et al. AJR 1992

6
CT Scan for HCC Diagnosis
  • Diagnostic procedure of choice.
  • Arterial phase CT is vastly superior to double
    phase scanning.
  • The sensitivity of CT is much greater than
    ultrasonography (80 vs 60).
  • Chalasani N, et al. Am J Gastro 1999

7
The CT Modality of Choice
  • Recent lipiodol studies have shown reduced
    sensitivities compared to initial reports.
  • Reduced sensitivity compared to triple phase CT.
  • Ngan H. Br J Radiol 1990
  • Nakayama A, et al. Ann Surg 2001

Earlier Report Recent Report
Sensitivity 93 97 78
8
AngiographyDoes the Route Make Any Difference ?
  • 109 patients with HCC.
  • Sensitivity of angiographic interventions
    studied.
  • CT Lipoidol 80.
  • CT Portography 84.4.
  • CT Angiography 91.3.
  • CT portography revealed additional 15 lesions
    that had significant therapeutic alterations.
  • Malagari K Hadziyannis S. Hepatogastroenterology
    1999

9
To Biopsy or Not to Biopsy
  • Pre-existing cirrhosis mass gt2 cm
  • gt95 chance of HCC.
  • Pre-existing cirrhosis mass lt2 cm
  • 75 chance of HCC.
  • Frazer C J Gastro Hepat 1999
  • Horigome H, et al J Gastro Hepatol 1999

Only where considerable doubt exists, will a
biopsy of the lesion be required. BSG Guidelines
Ryder SD, Gut 2003.
10
Needle Track Seeding
  • Incidence of 1 - 2 for each biopsy attempt.
  • Incidence lower with FNA than tru-cut.
  • Needle track seeding converts curative resection
    to palliative.
  • False-positive clinical/radiological diagnosis
    about 3.
  • 20 in HCC lt3cm and low AFP
  • Levy I, et al. Ann Surg 2001

11
BiopsyThe Guidelines
  • Lesions lt1 cm should not be biopsied.
  • Lesions 1 - 2 cm should have FNA biopsy.
  • Conclusions of EASL 2000, J Hepatol 2001
  • Bruix J, et al. AASLD Guidelines 2005
  • Lesions gt2 cm should not be biopsied in presence
    of diagnostic clinical criteria.
  • Conclusions of EASL 2000, J Hepatol 2001
  • Abdo A, et al. Saudi Guidelines for HCC, Ann
    Saudi Med 2006
  • Bruix J, et al. AASLD Guidelines 2005

12
Setting Diagnostic Criteria
  • Histological diagnosis.
  • Presence of classic appearance in one imaging
    modality AFP gt400 µg/L appropriate clinical
    setting.
  • Presence of normal AFP classic (gt2 cm nodule,
    arterial vascularity) appearance in two imaging
    modalities appropriate clinical setting.
  • Saudi Guidelines for HCC, Ann Saudi Med 2006
  • Conclusions of EASL 2000, J Hepatol 2001

13
Surveillance and Recall Strategy for HCC
Cirrhotic patients (US AFP/6 m)
Liver nodule
No nodule
?1 cm
lt1 cm
Increased AFP
Normal AFP
lt2 cm
gt2 cm
US/3m
Spiral CT
FNAB
AFP ?400 ng/mL CT/MRI/Angiography
No HCC
HCC
Surveillance US AFP/6 m
AFP levels to be defined Pathological
confirmation or non-invasive criteria
14
Decision making in HCC Treatment
  • The status of the non-tumorous liver
  • Underlying cirrhosis.
  • Non-cirrhotic liver (HBV).
  • Size and extension of the tumour
  • Is it 5 cm in size/3 lesions 3 cm ?
  • Vascular involvement.
  • General condition of patient, the age and
    expected life expectancy.

15
Liver Transplantation for HCC
  • HCC is the curative intervention of choice
  • Survival 75 at 5 years.
  • Data comparable to non-HCC LT.
  • HCC require priority listing for LT.
  • Living Donor LT can be offered.
  • Milan Criteria serve as threshold for LT option
    (single lesion lt 5 cm 3 in number, lt 3 cm).

Conclusions of EASL 2000, J Hepatol 2001 Saudi
Guidelines for HCC, Ann Saudi Med 2006 Bruix J,
et al. AASLD Guidelines 2005
16
Liver Transplantation for HCCExpanding the Milan
Criteria
UCSF Criteria (single lesion lt 6.5 cm 3 in
number, lt 4.5 cm combined diameter lt 8cm)
Survival
Milan Criteria 94 88
UCSF Criteria 90 90
Yao et al. Hepatology 2005, 197A
17
The Optimal Resection Candidate
  • All non-cirrhotic patients with no extrahepatic
    spread (Western 5, Asian 40).
  • When cirrhosis present - 30
  • Child-Pugh class A.
  • No portal HTN.
  • Pr. gradient gt10 mmHg
  • Oesophageal varices
  • Splenomegaly ? plats lt105
  • Patient is not a candidate for LT treatment.
  • Solitary lesions lt5 cm.

18
ResectionsOutcome
  • Recurrence
  • 5 years gt70.
  • Survival
  • 3 years 38 - 65.
  • 5 years 33 - 44.
  • Decompensation
  • 50.

Song TJ, et al. Gastroenterology 2004
19
Local Ablative Therapies for HCCPEI Livraghi T,
et al., J Hepatol 1995
Survival 3 years, 391 patients, 1 lesion, lt5 cm
Child - A Resection 79 (p lt0.001) P E I 71 (p lt0.001) No Treatment 26
Child - B Resection 40 (p lt0.01) P E I 41 (p lt0.001) No Treatment 13
20
Local Ablative Therapies for HCC
  • Radiofrequency Ablation (Lencioni R et al,
    Radiology 2003)
  • Randomized trial RFA vs PEI.
  • Child A or B in accordance with Milan criteria.

Survival 1 year 2 years
RFA 100 98 p 0.138
PEI 96 88 p 0.138
Survival 1 Year 89 3 years 62 5 years 33
Buscarini L et al., Eur Radiol 2001
21
Rationale for Embolization Therapy
  • HCC blood supply gt90 from hepatic artery.
  • Normal liver 70 - 80 blood supply from portal
    vein.
  • Breedis et al, Am J Pathol 1954
  • Occlusion of blood supply may cause tumor
    necrosis in up to 95 of lesion.
  • Higuchi et al, Cancer 1994

22
Improved Survival with TACE
  • Systematic review of 7 RCT comprising 545
    patients.
  • Llovet Bruix, Hepatology 2003
  • (Chemo)embolization vs no treatment.
  • Significant improvement in 2 year survival.
  • Subanalysis showed significant benefit with
    chemoembolization but not with bland emolization.
  • Small tumors, good liver reserve
  • TACE 63
  • Bland 50
  • Control 27
  • Llovet et al, Lancet 2002

23
Guidelines Recommendation for TACE
  • The evidence for a survival benefit with TACE is
    sound and that this useful procedure should be
    used more often in the right clinical setting.
  • Saudi Guidelines for HCC, Ann Saudi Med 2006
  • TACE is recommended as first line non-curative
    therapy for non-surgical patients with
    large/multifocal HCC who do not have vascular
    invasion or extrahepatic spread.
  • AASLD Practice Guidelines HCC Hepatology 2005

24
Approach in Non-Cirrhotic Patient
No Cirrhosis
  • Resection candidate
  • Normal bilirubin
  • No portal HTN
  • No extra-hepatic spread
  • Technically resectable

Not Resection candidate
  • Multifocal (gt3)
  • Lesion gt4 cm
  • Less than 3 lesions
  • Smaller than 3 cm

Resection
TACE
TACE
Local ablation
Saudi HCC Guidelines. Ann Saudi Med 2006
25
Approach in Child-Pugh A Cirrhotic
Child-Pugh Class A
Timely transplant available
Yes
No
  • 3 lesions each lt3 cm
  • 1 lesion lt5 cm
  • No extra hepatic spread
  • Resection candidate
  • Normal bilirubin
  • No portal HTN
  • No extra-hepatic spread
  • Technically resectable

Not Resection candidate
Transplant
  • Multifocal (gt3)
  • Lesion gt4 cm
  • Less than 3 lesions
  • Smaller than 3 cm

Resection
TACE
TACE
Local ablation
Local ablative therapy or TACE may be used while
awaiting liver transplant
Saudi HCC Guidelines. Ann Saudi Med 2006
26
Approach in Child-Pugh B Cirrhotic
Child-Pugh Class B
Timely transplant available
Yes
No
  • Multifocal (gt3)
  • Lesion gt4 cm
  • 3 lesions each lt3 cm
  • 1 lesion lt5 cm
  • No extra hepatic spread
  • Less than 3 lesions
  • Smaller than 3 cm

Transplant
TACE
TACE
Local ablation therapy
Saudi HCC Guidelines. Ann Saudi Med 2006
27
Approach in Child-Pugh C Cirrhotic
Child-Pugh Class C
Timely transplant available
  • 3 lesions each lt3 cm
  • 1 lesion lt5 cm
  • No extra hepatic spread
  • Good performance
  • status
  • lt50 years old
  • Poor performance
  • status
  • gt50 years old

Transplant
  • Cirrhosis complication
  • management
  • Consider enrollment in
  • systemic chemotherapy
  • trials
  • Cirrhosis complication
  • management
  • Palliative symptomatic
  • treatment

Saudi HCC Guidelines. Ann Saudi Med 2006
28
Summary
  • HCC is essentially diagnosed by non-invasive
    criteria which is a combination of serology and
    imaging means.
  • Liver biopsy is to be performed only where
    considerable doubt exists for the diagnosis
  • Recent advances in ablative therapy (RFA) and
    improved survival with TACE are encouraging that
    these should be used more frequently.
  • LT remains the curative treatment of choice.

29
Saudi Gastroenterology Association
GuidelinesDiagnosis Management of
HCCTechnical Review Practice Recommendations
www.saudiannals.net/SGAHCCguidelines/
Write a Comment
User Comments (0)
About PowerShow.com