Hcc Flashcards
1
Q
Most frequent amplification hcc
A
1q- 57%
8q 46
6p 22
17q 22
2
Q
Mc oncogene hcc
A
P53 (tsg)- 18 &35%
& wnt b catenin (pog)- 15.9 %
3
Q
Ctnnb1 mutation liver
A
Larger in size
Wd
Without inflam features
4
Q
Tp53 hcc
A
PD
Pleomorphic
Vascular invasion
5
Q
Schrrhous hcc
A
TSC1/2
6
Q
Steatotic hcc
A
IL 6/ JAK/stat
7
Q
Macrotrabecular massive subtype
A
Poor outcome
High AFP
FGF19 amplifications
8
Q
Molecular hcc subtypes
A
Stromal s1
Stemness angiogenic-s2
Diff ctnnb1
Diff non ctnnb1
9
Q
Stemness marker
A
EPCAM
10
Q
Hbv-hcc
Hcv- hcc
Cirrhosis- hcc
A
54%
31%
1-8% yrly
11
Q
Hereditary conditions causing hcc
A
High Hemochromatosis- 3-4% annual risk, 23 times Antitrypsin Hereditary tyrosinemia Low- wilson, pbc
12
Q
Screening- 6 month usg >1 cm
Afp>20 ng
A
Hep b and c Alcoholic, nafld nash Antitrypsin def Cirrhosis Pbcholangitis stage 4
13
Q
LIRADS
A
1- def benign 0 2- probably 11% 3- intermediate prob of hcc 33 4- high prob hcc not 100% 80 - bx 5- def hcc 96% 5v- venous inv Lrm- non hcc ca 42% hcc, rest another tr
14
Q
Components of LIRADS
A
- Arterial phase hyperenhancement
- Size
- Washout and enhancing capsule
15
Q
Hcc growth pattern most common- nodular expanding pattern
A
Eggel's classification (1901): Nodular HCC Massive HCC Diffuse HCC Kaufmann's classification (1958) Large massive node HCC in cirrhotic liver (a) Multiple nodules (b) Diffuse growth (c) Combination of nodules and growth Okuda classification (1984) Expanding Spreading Multifocal
16
Q
Classf of hcc
A
Surgical classification:
Invading lesions ("invaders")
Expanding lesions (**pushers")
Pedunculated lesions ("hangers")
Classification of the Liver Cancer Study Group of
Japan (LCSGJ:
Nodular HCC (distinctly nodular type)
Simple nodular (SN) type
Simple nodular type with extranodular growth
(SNEG)
Confluent multinodular type (CMN)
Nodular HCC
Small nodular type with indistinct margins (vaguely
nodular type)
Classification according to size:
Small HCC
Solitary large HCC
17
Q
Architectural patterns liver
A
Schirrous
Acinar or pseudoglandular
Trabecular
18
Q
Fibrolamellar hcc
A
0.85% of primary liver cancer
13.4% of all cases in patients younger than 40
• Overexpression of neuroendocrine genes- prohormone convertase 1, neurotensin, delta/notch-like
epidermal growth factor- related receptor, and calcitonin.
histologic features are fibrous
stroma and large eosinophilic tumor cells
More LN inv
Cytokeratin 7 and 19
DNAJB1PRKACA Chimera
19
Q
Hcc with hypercalcemia
A
Sclerosing variant
20
Q
Hcc with hypoglycemia and hypercholesterolemia
A
Clear cell variant
21
Q
Grading of hcc
A
Edmondson and
Steiner system, which subdivides HCC into
four grades, from I to IV
22
Q
Marker distinguishing benign and malig hep lesions
A
Glypican-3
23
Q
Hepaticellular differentiation markers
A
HepPar1 and arginase
24
Q
Criteria for Non Invasive Diagnosis in HCC
A
Lesions > 2 cm
Arterial enhancement and venous washout on 1
imaging modality either on CT/MRI/USG or
angiogram
Only arterial enhancement on 2 contrast studies
Lesions 1 - 2 cm
- Arterial enhancement and venous washout on 2
imaging modalities
Arterial enhancement alone and &FP > 200 ng/ml
25
Child pugh
Class A = 5 to 6 points (least severe liver disease)
Class B = 7 to 9 points (moderately severe liver disease)
Class C = 10 to 15 points (most severe liver disease)
26
Okuda
```
Bb -3
Alb-3
Tumr size >50%
Ascites+/-
Stages 1-3
```
27
CLIP
Child
Lab-AFP
Image- tumour morph
PVthrombosis
28
Tnm hcc
T1a Solitary tumor <2cm
T1b Solitary tumor >2 cm without vascular invasion
T2
Solitary tumor >2 cm with vascular invasion, or multiple
tumors, none >5 cm
T3
Multiple tumors, at least one of which is >5 cm
T4
Single tumor or multiple tumors of any size involving a major
branch of the portal vein or hepatic vein, or tumor(s) with
direct invasion of adjacent organs other than the gallbladder
or with perforation of visceral peritoneum
N0,N1
29
Node postivity becomes stage 4 in
1. Hcc
2. Sarcoma
3. Ubladder
30
Regional nodes for liver tumor
Hepatoduodenal
Hilar
Inferior phrenic
Caval
31
Ishak scoring system for
Fibrosis score 0-4- F0- none to mod fibrosis
5-6- F1- sev fibrosis or cirrhosis
METAVIR system- f0- f4
32
Markers of hcc
```
Afp
Des gamma carboxy prothrombin
Pivka 2
Ferritin
Alpha 1 Fucosidase
```
33
Hjortsjos crook
The right posterior sectional duct normally
hooks over the origin of the right anterior
sectional portal vein ("'Hjortsio's crook'),6
where it is in danger of being injured if the
right anterior sectional pedicle is clamped too
close to its origin
34
Mc benign tr of liver
Hemangioma -70% f>m
Mean age-45
Multiplicity percentage- 10
Estrogen receptor
35
Kasabach merrit syndrome
Consumption coagulopathy
36
Ct diag of hemangioma
```
1.
Low attenuation on noncontrast CT.
2. Peripheral and globular enhancement of the
lesion followed by a central enhancement on
contrast CT
3.
Contrast enhancement of the lesion on
delayed phases
BLOOD POOL SIGN
MRI- LIGHT BULB PATTERN
```
37
Focal nodular hyperplasia
```
F>m
30-50 yrs
Second m/c
20%multiple
CENTRAL FIBROUS SCAR
```
38
Hepatocellular adenoma
```
F>m
Bleed and malig change
Ocp dose dependent
Multiplicity-12-30%
Sonic hedghog-5% assoc with obesity and adenoma
```
39
Hep cellular adenoma genetic syndrome
GSD- 1a
Mccune albright
Mody-3
Fap?
40
Subtypes of hca
1. HNF1Q-mutated HAS (HNF1A);
2. Inflammatory (also known as telangiectatic)
HAS (IHCA)- obesity
3. ß-catenin- mutated HAs (b-HCA); increased malig risk
4. Unclassified subtypes
41
Risk factor for bleed in hca
• 25% of patients.
Risk factors for hemorrhage
1.Large tumors (>5 cm, especially in the IHCA
subtype)
2.Visualization of arteries within the lesion
•3.Location of the tumor in the left lateral liver
4.Exophytic growth
42
Hca malig transformation
```
Risk - 5%
to 6%.
•
Lower risk in women.
Risk factors for malignant transformation:
•1.Sex (with a 6- to 10-fold higher risk of
malignant transformation in men)
2.Androgen use
•3.B-HCA subtype
• 4.Tumor diameter of greater than 5
cm
(independent of the subtype).
5.IHCAs containing B-catenin mutations
```
43
Hca indication for LT
a. Multiple unresectable lesions in men
b. Large HCA associated with intrahepatic venous shunt
c. Patients with glycogen storage disorders unresponsive to medical treatment.
44
Inflammatory pseudotumor of liver
Inflam myofibroblastic tumors
80% symptomatic
Benign
T/t - surveillance steroid and antibiotics
45
Cystic neoplasm of hepatobiliary
```
Biliary cystadenoma -mucon, ovarian stroma,females m/c seg 4
Biliry IPMN
biliary cystadenoca
Cystic intrahep changioca
NET..
```
46
```
30. What is the future liver remnant aimed at
before planning for liver resection in non
cirrhotic patients
a. 25%
b. 15%
C.
40%
d. 50%
```
Volumetric analysis:
25% of liver remaining without underlying
parenchymal disease
40% with underlying liver disease.
47
31.
What is true about Indocyanine green
clearance test?
a. Should be administered within 1 hour after
food intake
b. > 20 % retention rate - hepatectomy should
be performed.
C. <14% - hepatectomy is contraindicated.
d. None of the above.
```
•
Should
be administered
after
over
night
fasting.
Retention rate
<14
%
Good functional
volume.
>20% - Contraindication to the surgery.
```
48
Assessment preop liver
```
Assessment
I Clearance/retention tests
A
Indocyanine green (ICG)
B
Lidocaine/Cyp1a2-monoethylglycinexylidide(MEGX)
C99tc mebrofenin radioisotope
Galactose elimination capacity
D
Aminopyrine breath test 13C
E
Hippurate ratio
F
Trimethadione/dimethadione(TMO/DMO)
G
Amino acid
H
Caffeine
T
Antipyrine
I Redox chemistry
A
Arterial ketone body ratio (AKBR)
B
Redox tolerance index (RTI)
III Volumetry
A
B
Computed tomography (CT)
Magnetic resonance imaging (MRI)
IV Scintigraphy
A
99m technetium galactosyl human serum
albumin (99m Te-GSA)
```
49
Brisbane classification -2000
Liver resection
50
Gd EOB-DTPA liver tumors
Useful in small tumors
Low specificity and high sensitivity
Malig cells dont show takeup
51
Local ablation therapies
| -<3cm
1.Chemical- 95%etoh 5%acetic acid
Coag necrosis dehydration vasc thrombosis
In <2cm
2.thermal -D+2, circumferentialy 1 cm
a)Cold- cryo iceball creation less than -40degreeC
b)Heat- 60degree
rfa and microwave- radiant cooling effect allows near vasc structure
3. Irreversible electropolation
Non thermal, pulsed DC, transmembrane potential , no heat sink , leads to cell memb perforation
52
Criteria for liver transplant
Milan and UCSF
53
MILAN
Single tr = 5 cm
Upto 3 trs all les than 3 cm
Absence of macrovascular invasion and extrahepatic spread
54
UCSF
Single tr less than 6.5 cm
Multiple less than 3 nodules all less than 4.5 cm
Total les than 8 cm
55
MELD
Bb
Cr
INR
56
Transarterial treatment hcc chemo
```
90-100% HA SUPPLY
Pv gives 75 % to liver though
Agents- Doxorubicin
Cisplatin
Epirubicin
Mitoxanteone
Mitomycin C
```
57
Embolic materials liver
```
Agents:
Gelatin sponge particles
Polyvinyl alcohol (PVA) particles,
Calibrated microspheres,
• Absolute ethanol,
Starch microspheres
• Cyanoacrylate
```
58
Taradioembolisarion in hcc
Yt 90- beta rays
| Microspheres therasphere or resin -Sirte x
59
Indications for tace
```
Unresectable child a
Child b
Bclc a
Bridge to transplant - new
Na therapy
```
60
Adjuvant in Hcc trial name?
STORM - no role FOR ACT OR NACT
61
Systemic treatment for hcc
Tkinhib- SORAFENIB
| ALSO VEGF PDGRF BLOCK
62
Role of sorafenib
| 400 mg bd dose according to bb and alb
Sharp trial role in advanced
Asia pacific- hep b hcc
In child A pt
If bb more than 3 times uln - dont give
63
S/e of sorafenib
Hsfr
