19 - Hepatocellular Cancer Flashcards
Hepatocellular Cancer - Epi
Incidence is now in the top 10 for men
Death rate top 5 in the USA
Worldwide, 4th leading cause of death
Hep B!!!!
Most HCC worldwide is HBV-related
Often vertical transmission
HCC may develop without cirrhosis. HBV may be the direct carcinogen
Western world:
HCV plays a larger role
Acquired later in life
Almost ALWAYS associated with cirrhosis
HCC - Risk Factors
Exposures:
HCV EtOH, Aflatoxin (mold on peanuts and corn)
HBV
Genetic Susceptibility:
Hereditary hemochromatosis
Alpha-1 antitrypsin deficiency
Metabolic Factors:
NASH
Metabolic Syndrome
Demographics:
Older Age
Male Sex
How to screen for HCC
Ultrasound every 6 months
If a mass is found cirrhotic, evaluate based on imaging
AFP should not be used alone unless ultrasound is not available
Cost-effective to screen if annual HCC > 1.5%/hear (Cirrhotics: 3% - 5%/ year)
Who has a higher risk of HCC from non-cirrhotic etiology?
Asian male HBV carriers over 40
Asian female HBV carriers over age 50
African/North American Blacks with HBV
HBV carrier with family history of HCC
Screening for HBV before Chemo
Anyone you think is high risk should have an HBSAg test for chemo. If positive, give antivirals before chemo
Milan Criteria for Liver Transplant, re: tumors
If only one tumor, it must be 5cm or less
3 or fewer tumors, each 3cm or less
No gross vascular invasion
Other therapies for HCC
Resection - If underlying liver function is good
Local therapy:
Radiofrequency ablation - works well for tumors
Emboliztion
Normal liver receives most blood from portal vein, only 25% from hepatic artery.
Tumors receive MOST of their blood supply from the hepatic artery
Dual therapy - Both embolization and chemotherapy (or radiolabeled beads) to branches of the hepatic artery.
Improves survival - Not a cure, though. Bridge to transplant.
HCC - Adjuvant Therapy
No proven benefit after resection or ablation
HCC - Systemic chemotherapy
Sorafenib
Improves survival by about 3 months
Sorafenib - Side Effects
Hand-foot reaction (21%) - Benefit with up front urea cream
Diarrhea 39%
Anorexia 14%
Bleeding 7%
Blocks VEGF
Other Drugs for HCC
Monoclonal antibodies and smallecule inhibitors to new targets show promise:
Cabozantinib/Tivantinib - C-MET TKIs
Becizumab - VEGFA Ab inhibitor
Erlotinib - EGFR TKI
Stage 0
Single tumor
Portal pressure/bilirubin normal
Resect or ablate
Stage A
If they meet milan criteria
Liver transplant or PEI/RV
Stage B
TACE (embolization)
Stage C
Sorafenib
Stage D
Symptomatic management
Biliary Cancers - Epi
Gallbladder:
US & Chile - Gallstones
India - Salmonella/chronic typhoid
Bile Duct Cancers:
US - PSC, Metabolic syndrome, HCV
Asia - Liver flukes
Biliary Cancers - Genetics
BRCA2
HNPCC
Peutz-Jeghers
APC syndromes
All lead to increased risks of biliary cancers
Ampullary cancers are not technically “Biliary” but should make you strongly consider FAP. Do a colonoscopy!!!
Biliary Cancers - Treatment
Resect if you can
Very select cases can be transplantable
Adjuvant - still being defined
New chemo regimens show promise for advanced disease
Liver Mass work up - broad
Non-Tumor:
Cysts
Abscess
Tumor:
Benign:
Hemangioma
Hepatocellular adenoma
Focal Nodular Hyperplasia
Malignant:
Metastasis
HCC (Most common mass to find)
Cholangiocarcinoma
Liver Mass Work Up - Young women
Hemangioma
Adenoma
Focal nodular hyperplasia
Liver Mass Work Up - Not young women
Metastases
Infections
Liver mass work up - underlying liver disease
HCC
Benign Mass
Non-Tumor:
Cyst - Bile Duct (DPMs), Echinococcus
Abscess
Benign Tumors:
Hemangioma
Focal Nodular Hyperplasia
Liver Cell Adenoma
Amebic Abscess sign on imgaing
Halo
Causes of liver abscess
Bacterial
Parasitic (Amoebic)
Hepatic Artery - Sepsis
Cholangitis
Pylephlebitis (portal vein inflammation) - Ruptured appendix, perforated ulcer
Amoebic Colitis - E. Histolytica
Malignant
Metastasis (the most common tumor IN the liver)
HCC
Bile duct carcinoma
Hemangioma
Most common benign tumor of the liver
Tumor of blood vessels
Incidental at autopsy/surgery
Can cause pain/rupture
Adenoma
Benign tumor of hepatocytes
No bile ducts present
Risks:
OCPs
Hepatocyte nuclear factor 1-α mutations
GSD Type 1
Bigger than 5cm, can progress
NO BILE DUCTS
Thick plates
Focal Nodular Hyperplasia
Central scar
Polyclonal malformation
Hyperperfusion
Bile duct proliferation
If you have underlying liver condition and you have cancer
HCC 80%
The rest are cholangiocarcinomas
Malignant Liver Tumors
Primary:
HCC, Cholangiocarcinoma
Metastasis:
Colorectal
Pancreas
Others
HCC
75% of patients have cirrhosis
75% serum AFP+
Risks:
Cirrhosis due to HBV, HCV, EtOH, Hemochromatosis
Invades veins:
Portal vein/hepatic vein/IVC - to lungs
