Transcript HCC
SIR RFS IO Service Line
Created by: Colin Burke
10-22-13
Images from:
Vascular and Biliary Variants in the Liver: Implications for Liver Surgery: Radiographics March-April 2008 28:2 359-378
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www.deltagen.com
www.wikipedia.org
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5th most common cancer
Fastest growing cause of cancer mortality
Risk Factors
HBV
HCV
Cirrhosis
Alcoholism
Biliary cirrhosis
Hemochromatosis
NAFLD
Aflatoxins- Esp. in Asian population
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Multifactorial, exact
mechanism unclear
Inflammation, necrosis,
fibrosis, regeneration of
cirrhotic liver
Environmental toxins
Mistakes in regenerative
pathway
Gene mutations: p53, B catenin
Main Theory
Repeated necrosis &
www.livingwithcancerinternational.com
regeneration + genetic
material in viral hepatitis =
mutations & abnormal cell
proliferation
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Jaundice, pruritis
Ascites,
Abdominal Pain
Variceal bleed
Encephalopathy
Paraneoplastic syndromes
Unintentional weight loss
Image from: http://www.mcemcourses.org/wpcontent/uploads/case9picture.jpg
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Chronic Liver Disease: Screen with US every 6 months
AASLD Guidelines
Asian men over 40 & Asian woman over 50
Patients with HBV & Cirrhosis
African & North American Blacks
Patients with a family history of HCC
US results
Nodule < 1 cm
Usually not HCC, monitor every 3 months until they disappear
Nodules > 1 cm
Evaluate with CT/MRI
Biopsy only if unable to diagnose on imaging findings
Lab Studies
Nonspecific:
Anemia, thrombocytopenia, increased LFTs,
AFP
Raises concern, especially when over 200 mg/dl
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US
Small hypo-echoic lesion
Heterogenous (fibrosis,
fatty change &
calcifications)
Hard to distinguish from
cirrhosis
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CT
Focal, multifocal diffuse, infiltrative or atypical
Hypervascularity in arterial phase, washout in portal and delayed
phases
Focal necrosis and calcification (10%)
Capsule (24%)
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MRI
T1
Variable
Isointense or hyperintense
compared to surrounding
liver
T2
Variable, typically
hyperintense
Post-gadolinium
Arterial-phase enhancement
+/- discrete feeder vessels
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Unresectable: mortality within 3-6 months
Resectable: partial hepatectomy curative due to
regenerative nature of liver
2/3 of the liver can be resected
Role of portal vein embolization prior to partial
hepactectomy
IR embolizes the right portal vein, stimulating
hypertrophy of noninvolved lobe & can qualify the
patient for resection or bridging to Tx
5 year survival if resectable: 37-56%
Only 10-20% are completely resectable
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Medical Therapy
Minimally responsive to
chemotherapy
Sorafenib (tyr-kinase inhib) used
for advanced cases
Mainly Palliative
Lactulose titrated to 2-3 loose
stools/day to control
encephalopathy in cirrhosis.
Diuretics to control ascites
Antibiotic prophylaxis to prevent
SBP
Surgical Therapy
Liver transplant
Resection
Small lesions may be cured under
RFA done by IR
http://www.ppdictionary.com/viruses/carcinoma_hepatitis_
b.jpg
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Unresectable tumors
Increase survival, improve
quality of life, currently not
intended for cure
Slows progression and is
palliative. Also used to help
patient’s survive partial
hepatectomy or act as a bridge
to transplant.
Terminology
Transarterial
Chemoembolization: TACE
Radiofrequency Ablation:
RFA
Selective Internal Radiation
Therapy: SIRT
Portal Vein Embolization:
PVE
http://www.anes.ucla.edu/images/news/large/DSC02293.jpg
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Percutaneous transhepatic
approach
Embolization of portal vein
supplying lobe of liver with the
tumor
Compensatory hypertrophy of
surviving lobe can qualify patient
for resection
Patients initially unresectable due
to insufficient remaining normal
parenchyma may qualify
Post resection morbidity
decreased
Right PVE:
http://radiographics.rsna.org/content/22/5/1063/F13.
expansion.html
Serve as a bridge to transplant
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Selective injection of antineoplastic agent
with a radiopaque contrast agent (lipiodol)
and embolic agent (gelfoam)
Higher dose of chemotherapy due to
decreased systemic exposure
Post Procedure
Post Embolization Syndrome
Hospital stay of 1-3 days
Decreased energy in the following 2
months
Abominal Pain, transaminitis
Follow up CT several weeks later to check
for tumor response
Repeat TACE
Only 2% of patients have complete
response from 1 procedure
Considered non-curative (unlike RFA)
Base repeat treatment on tumor response
and hepatic reserve
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Destroys tumor using
thermal energy from high
frequency radio waves
Usually used for small
tumors (< 3cm)
US guided percutaneous
approach
Post Procedure
Follow up CT/MRI several
weeks later to check for
tumor response. Can also
follow AFP
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Similar to chemoembolization
Uses radioactive microspheres
Radioactive isotope Yttrium (Y-90) incorporated into
radioactive spheres
Spheres selectively injected and get lodged in tumor
capillaries and proximal vascular supply
Localized brachytherapy
Combined radiation and ischemia results in cell
death.
Post Procedure
Post embolization syndrome with fatigue,
constitutional symptoms, and abdominal pain
Follow up CT/MRI several weeks later to check tumor
response. Can also follow AFP. Return to IR if AFP
remains increased. Monitor for variceal bleeds and
assessment of underlying liver function.
http://www.rwjuh.edu/images/cancer/sirt
image2.jpg
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TACE
Post Embolization Syndrome
Liver Failure
Post Embolization Syndrome
20-55%
Hepatic Dysfunction
RFA
3-5%
Non target embolization into left gastric
SIRT
Dependent on preprocedure liver function
20% of patients, irreversible in 6%
Gastroduoenal ulceration
60-80% of patients
Fatigue, constitutional symptoms, abdominal pain
Symptoms last 3-4 days, full recovery in 7-10
Complications are rare but include abscess formation, subcapsular hematoma and tract seeding
If HCC is not treated
TNM staging:
5 year survival 55%, 37% and 16% for stage I, II, III respectively
Okuda system: tumor size and degree of cirrhosis
8.3, 2.0 and 0.7 months for stage I, II, and III respectively
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HCC: Relatively poor prognosis including both high
morbidity and mortality
Main risk factors are chronic liver disease such as HBV,
HCV, and cirrhosis
Patients often present with decompensation of chronic
liver disease
Medical management generally palliative, aimed at
reducing liver disease symptoms, chemotherapy is
traditionally ineffective
Surgical resection and transplant can be curative
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Screen high risk patients with US, f/u with CT/MRI
IR procedures traditionally palliative for
unresectable tumors and those patients who are not
yet candidates for liver transplant
Growing evidence suggesting increased role for IO
therapies
Smaller (<4cm) or solitary lesions managed with
RFA
Large or multifocal tumors = TACE or SIRT
Insufficient data for combination RFA and TACE
Efficacy (complicated and conflicting data)
TACE: Objective response: 6-60%. Most studies show
increased survival vs conservative treatment
SIRT: Comparable to TACE
RFA: can be curative. 80-90% response for tumors<3
cm
Common complications: Post embolization
syndrome and hepatic dysfunction
www.barrieronline.com
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Catalano OA, Singh AH, Uppot RN, Hahn PF, Ferrone CR, Sahani DV.Vascular and Biliary Variants in the Liver: Implications for Liver
Surgery: Radiographics March-April 2008 28:2 359-378
Furuta T, Maeda E, Akai H, Hanaoka S, Yoshioka N, Akahane M, Watadani T, Ohtomo K.. Hepatic Segments and Vasculature: Projecting CT
Anatomy onto Angiograms. Radiographics. November 2009 Nov;29(7):1-22.
Madoff DC, Hicks ME, Vauthey JN, Charnsangavej C, Morello FA Jr, Ahrar K, Wallace MJ, Gupta S. Transhepatic portal vein embolization:
anatomy, indications, and technical considerations. Radiographics. 2002 Sep-Oct;22(5):1063-76
Yang ZF, Poon RT. Vascular changes in hepatocellular carcinoma. Anat Rec (Hoboken). 2008 Jun;291(6):721-34
Roche SP, Kobos R. Jaundice in the adult patient. Am Fam Physician. 2004 Jan 15;69(2):299-304
Uptodate
Clinical features and diagnosis of primary hepatocellular carcinoma. http://www.uptodate.com/contents/clinical-features-anddiagnosis-of-primary-hepatocellular-carcinoma?source=see_link. Last Updated Sept 23, 2013. Accessed October 20th 2013.
Epidemiology and etiologic associations of hepatocellular carcinoma http://www.uptodate.com/contents/epidemiology-and-etiologicassociations-of-hepatocellular-carcinoma?source=see_link. Last Updated August 30 2013. Accessed October 21, 2013
Prevention of hepatocellular carcinoma and recommendations for surveillance in adults with chronic liver disease.
http://www.uptodate.com/contents/prevention-of-hepatocellular-carcinoma-and-recommendations-for-surveillance-in-adults-withchronic-liver-disease?source=see_link. Last Updated July 12, 2013. Accessed October 20, 2013
Surgical management of potentially resectable hepatocellular carcinoma. http://www.uptodate.com/contents/surgical-managementof-potentially-resectable-hepatocellular-carcinoma?source=preview&anchor=H1061867819&selectedTitle=2~150#H1061867819 . Last
Updated May 22, 2013. Accessed October 23, 2013
Nonsurgical therapies for localized hepatocellular carcinoma: Transarterial embolization, radiotherapy, and radioembolization
http://www.uptodate.com/contents/nonsurgical-therapies-for-localized-hepatocellular-carcinoma-transarterial-embolizationradiotherapy-and-radioembolization?source=preview&anchor=H1248650314&selectedTitle=1~16#H1248650342 . Last Updated Sept 6
2013. Accessed October 23,2013
Inteventional Radiology Treatments for Liver Cancer. http://www.sirweb.org/patients/liver-cancer/. Accessed October 2014
Anatomy of Liver Segments. http://www.radiologyassistant.nl/en/p4375bb8dc241d/anatomy-of-the-liver-segments.html Accessed October
2013
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Image addapted from: http://www.utmb.edu/surgicalpathology/picts/photo_of_the_month_2006_2007/pom_aug_06.jpg
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