HCC FRCR CO2A Flashcards
male: female ratio for incidence of HCC
3: 1
High risk areas worldwide for HCC
East and SE Asia and sub saharan Africa
association with Hepatitis
Yes, Hep B
RFs and Aetiology
Infective
HBV and HCV
RFs and Aetiology
Inflammatory
Hereditary haemochromatosis
wilson’s disease
Type I glycogen storage disease
RFs and Aetiology
Chemical Injury
Alcohol
Aflatoxins
aflatoxins interact with alcohol to increase the risk of HCC threshold
mutations in HCC
TP53 (25 to 40 %)
Beta catenin (25 %)
what % of tumors don’t produce AFP?
30 %
Symptoms of HCC
usually asymptomatic, incidental finding
may present with liver decompensation features
what are liver decompensation features?
Ascites
Jaundice
anorexia
GI bleeding
wt loss and
encephalopathy
Diagnosis of HCC
CT / MRI criteria
where CT/MRI criteria can be applied
only cirrhotic patients
feature of HCC on imaging
Hypervascularity in arterial phase with washout in the portal venous phase
when should biopsy for HCC be avoided?
- not a candidate for therapy due to poor PS
- resection of tumor without acceptable morbidity/mortality or
- pts with decompensated disease awaiting liver transplant
who should be kept on surveillance for HCC
- established Cirrhosis
- Non cirrhotic HBV pts with high viral load
- HCV pts with bridging fibrosis
how is surveillance for HCC done
USG every 6 months
surveillance result and action for new nodule
nodule < 1 cm, repeat USG at 4 monthly for 1 year then 6 monthly
nodule 1 to 2 cm, on surveillance
4 phase CT or Dynamic contrast enhanced MRI , if hall mark of HCC Not seen, biopsy, 2nd biopsy if 1st inconclusive
nodule > 2 cm
4 phase CT or Dynamic contrast enhanced MRI , if hall mark of HCC Not seen, biopsy
if biopsy again inconclusive, 4 monthly USG
curative options for HCC
resection
liver transplantation
Ablative therpies
when is local resection Rx of choice
non cirrhotic livers and for pts with Child pugh A solitary tumor and minimal portal Hypertension
Liver Transplantation in HCC
Milan Criteria
- 1 tumor between 2 and 5 cm or 2 to 3 tumors, all < 3 cm;
C/Is for TACE:
- thrombosis in main portal vein
- encephalopathy
- Biliary Obstruction and
- Child Pugh C
SBRT dose for HCC used in studies
50 Gy in 3 to 10 fractions
when is SBRT useful
pts with portal vein thrombosis
SABR UK consortium, SABR inclusion criteria:
- Tumors deemed unresectable after review by hepatobiliary MDT
- Volume of uninvolved liver > 700 cc
- platelets > 800000
- Bil: < 3 x ULN
- AST/ALT < 5 x ULN
- INR < 1.3
- Creat < 200 micromol/L
- Child Pugh Class A
Exclusion criteria for SABR
- active hapatitis
- any signs of liver failure
- ascites, clinically detectable
- CNS mets or coagulopathy
mean dose of liver should not exceed 15 Gy
methods of managing respiratory motion for HCC
- abdominal compression
- active breathing control
- respiratory gating
- tumor motion tracking by placement of fiducial
to what level, respiratory motion be minimized?
< 5 mm
Dose schedule for SABR for HCC
45 to 48 Gy in 3 fractions over 8 to 10 days or 50 to 60 Gy over 14 days
Selective Internal targeted therapy for HCC
Source and Dose:
Yttrium 90
120 Gy
unresectable or metastatic HCC Systemic therapy
Atezolizumab + bevacizumab , cat 1
role of adjuvant chemotherapy
no
S/Es of sorafenib
FAtigue
diarrhoea
HFS and skin rash
Hypertension
Bleeding
Liver Dysfunction
Doxorubicin in HCC
response rate
of 15 to 25 %
stage wise 5 yr survival HCC
stage I : 60%
II: 45 %
III : 20%
IV : 10. %
Angiosarcoma of liver cause
exposure to polyvinyl chloride monomers
occur 10 to 20 yrs after exposure
Rx of angiosarcoma of liver
resection where feasible or palliative anthracycline chemo
