HCC

Question 1

What are the 5 measures that make up the child Pugh score?

Answer 1

Bilirubin (<34 (1), 34-50 (2), >50 (3))
Albumin (>35 (1), 28-35 (2), <28 (3))
INR (<1.7 (1), 1.71-2.2 (2), >2.2 (3))
Ascites (nil (1), mild (2), severe (3))
Hepatic encephalopathy (nil (1), G1-2 or suppressed with meds (2), g3-4 (3))

Class A = 5-7
Class B = 7-9
Class C = >10

Question 2

What is the vascular hallmark of HCC on dynamic imaging?

Answer 2

Hypervascularity in arterial phase with washout in portal venous phase

Question 3

What investigations should be performed in suspected HCC?

Answer 3

Medical hx & exam
FBC, renal, liver fx, bone profile, clotting,HBV, HCV serology and AFP
Dynamic contrast enhanced MRI
CT TAP
Biopsy (only if suitable for radical tx, can be omitted if cirrhosis and classic features on imaging)
Upper endoscopy (?varices)

Question 4

What staging system can help to determine tx?

Answer 4

Barcelona clinic liver classification

Question 5

What is the 1y survival for child’s-Pugh class A patients?

Answer 5

100%

Question 6

What is the 1y survival for child’s Pugh class B pts?

Answer 6

81%

Question 7

What is the 1y survival for child’s Pugh class C pts?

Answer 7

45%

Question 8

If someone is child’s Pugh class C, what BCLC group are they in?

Answer 8

Stage D (BSC). MOS 3m

Question 9

If some one has portal vein invasion or nodal/distant mets but child’s Pugh class A and PS1, what BCLC group are they in?

Answer 9

Stage C - for systemic treatment.

Question 10

What is first line systemic treatment for pts with advanced disease not suitable for ablative tx or TACE? (Providing child’s Pugh class A and good PS?)

Answer 10

Atezolizumab & bevacizumab

(Sorafenib if unable to receive immunotherapy)

1y OS 67%
MPFS 6.8m
(15% G3/4 hypertension)

Question 11

What is standard treatment for BCLC stage B?

Answer 11

TACE

1y OS 82%, 2y OS 63%

Question 12

What criteria is used for suitability for liver transplantation?

Answer 12

Milan criteria

Single <5cm or upto 3 lesions up to 3cm, no extra hepatic disease, no vascular invasion

If fit these criteria, <10% recurrence, 70% 5y survival

Question 13

What segments of the liver are in the left lobe?

Answer 13

Segments 1-4

Question 14

What is the 1y local control for microwave ablation? (For BCLC stage 0-A)

Answer 14

70-80%

Question 15

What is the maximum size of a liver lesion that would be considered for SABR?

Answer 15

5cm

Question 16

Is there any surveillance scheme for pts with cirrhosis?

Answer 16

Yes. USS and AFP every 6 months (or 4m is there is a <1cm lesion)

Question 17

What adjuvant therapy is given following a liver resection for HCC?

Answer 17

None, no evidence for adjuvant treatment

Question 18

How is hepatic encephalopathy graded?

Answer 18

Hepatic encephalopathy can be graded using the Conn score (also called West Haven classification) in which higher scores indicate a higher severity, as follows:
Grade 0: No personality or behavioural abnormality detected.
Grade 1: lack of awareness, euphoria or anxiety, shortened attention span, impaired performance of addition.
Grade 2: lethargy or apathy, minimal disorientation for time or place, subtle personality change, inappropriate behaviour, impaired performance of subtraction.
Grade 3: somnolence to semi stupor but responsive to verbal stimuli, confusion, gross disorientation.
Grade 4: coma (unresponsive to verbal or noxious stimuli).

Taken from: https://www.nice.org.uk/guidance/ta337/documents/hepatic-encephalopathy-maintenance-treatment-rifaximin-draft-scope-for-consultation2

Question 19

What is the 1 and 2y local control rate following SABR? (As per RIM meta analysis)

Answer 19

85.7% and 83.6% respectively