HCC RPA

Question 1

Most common primary liver cancer is …

Answer 1

HCC

Question 2

90% HCC have…

Answer 2

Cirrhosis

In MAFLD, 30% can develop HCC without cirrhosis

Question 3

Causes of HCC

Answer 3

Hep B/C - decreasing in Australia
ETOH related liver disease - increasing in Australia
Metabolic liver disease (MAFLD) - increasing in Australia

Question 4

Prevention of metabolic associated HCC

Answer 4

Aspirin
Statin
Metformin

Question 5

Does aspirin reduce HCC and liver-related mortality?

Answer 5

Yes

Recent NEJM trial

Question 6

Clinical presentation of HCC

Answer 6

Screening program
- 6 monthly USS and AFP in cirrhosis and some chronic Hep B

Abdo pain, new onset ascites (vascular invasion), intraabdo haemorrhage

Incidental lesion on imaging

During transplant assessment in patients with decompensated disease

Incidental at time of transplant

Question 7

HCC surveillance how?

Answer 7

USS 6 monthly

AFP

CT/MRI not routinely used but may be used in obesity

Question 8

Who should have HCC surveillance?

Answer 8

Cirrhosis - up to 7% chance of HCC every year

People with chronic hep B infection without cirrhosis
Asian men >40
Asian women >50
Subsharan african >20
ATSI >50

Question 9

Liver Nodule at imaging

Answer 9

<1cm - repeat USS at 4/12 –> if growing, changing, the need contrast CT

> 1cm - multiphase contrast enhanced CT/MRI –> If HCC hallmark then no need for biopsy and can be diagnosed with HCC. If atypical features, then need biopsy (not done often)

Question 10

Features of HCC in 4 phase multislice helical CT scan

Answer 10

Arterial hyperenhancement

Washout on portal and delayed phase

Question 11

Management of HCC

Answer 11

BCLC staging system –> guide treatment

Options
Local Ablation (lesions <3cm) with ethanol or thermal
Resection
Transplant
Transarterial chemoembolisation (TACE) - delivery of chemotherapy through artery (femoral) to occlude arterial supply; cisplatin or doxorubicin or drug eluding beads
Selctive internal radiation therapy (SIRT) - delivery of radiation via hepatic artery. Difficult to deliver, risk of hepatotoxicity, very specialised, $$$ and not funded, not incooperated in guidelines due to limited evidence hence not used much.
Systemic therapy - TKi (sorafenib, lenvatinib) quite toxic; immunotherapy
Best supportive palliative care

Question 12

When to use systemic therapy in HCC?

Answer 12

ECOG 1
Not amenable to other therapies (lots of intrahepatic disease)
Good liver function
Advanced HCC

Question 13

Which systemic therapies are available in HCC?

Answer 13

1st line: Sorafenib, lenvatinib - Anti VEGF TKI.

2nd line: regorafenib, cabozantenib (not PBS at the moment)

NEW
Atezolizumab (anti-PDL1) + bevacizumab (anti VEGF)
- Superior to sorafenib, lenvatinib
- New 1st line therapy

Question 14

Sorafenib side effects

Answer 14

Diarrhoea
Hand foot skin reaction
LOA, LOW

Question 15

Lenvatinib side effects

Answer 15

Refractory HTN