HCC - with Prof Khan

Question 1

What are the main liver cancers?

Answer 1

HCC (80%)
Cholangiocarcinoma (15%)
Angiosarcomas/adenomas (rare)

Question 2

Epidemiology - how common is it in the world and how common is it as a cause of death?

Answer 2

5th commonest cancer in world
3rd leading cause with cancer related death

2-3 M> 1 F

Question 3

Where is HCC common?

Answer 3

Mongolia
China
Egypt
Sudan

Globally

Question 4

Risk factors for HCC in Monglia, Egypt, Sudan, West

Answer 4

Mongolia - Hep B/Hep C
Egypt - hep c
Sudan - Aflatoxin
West - fatty liver

Question 5

Risk factors

Answer 5

Chronic liver disease 
Cirrhosis
Hep B virus
Aflatoxin 
Betel nut chewing

Question 6

Protective factors against HCC

Answer 6

Coffee - e.g. polyphenols

improving fatty acid oxidation
Detoxifying enzymes
Reducing fibrosis

Question 7

Significant risk factor for HCC

Answer 7

Chronic Hep B - second most important human carcinogen to tobacco

Question 8

Outline how HCC develops

Answer 8

Cirrhosis -> nodules -> dysplastic nodules -> loss of p53 and other molecular changes, turns into HCC

Arteries growing / angiogenesis help

Question 9

Classifications of HCC

Answer 9

Well differentiated
Moderately differentiated
Poorly differentiated

Question 10

HCC is heterogenous. List some mechanisms that are dysregulated in HCC

Answer 10

Telomere maintenance
Cell cycle gene 
Wnt/Beta catenin 
Epigentic modifiers
Oxidative stress

Question 11

How do you screen for HCC

Answer 11

Ultrasound scan every 6months + serum AFP

5yr disease free survival over 50%

Question 12

Biomarker for HCC - what’s the downside?

Answer 12

AFP goes up in 2/3 with HCC

1/3 have normal HCC hence you have to do USS as well

Question 13

Four causes of raised AFP

Answer 13

HCC
Germ cell cancer e.g. teratoma/testicular cancer
Being a fetus
Pregnant woman carrying a fetus

Question 14

How is HCC diagnosed?

Answer 14

Biopsy OR

Diagnosis on imaging with contrast (contrast CT/MRI)

Question 15

Explain the photos taken in the MRI?

Answer 15

Triple phase contrast MRI:

1. Take image of whole liver
2. Inject contrast
   - when contrast in arterial phase of circulation, take photo because HCC heavily arterialised (compared to normal liver, which takes its blood from portal vein
3. Portal venous phase wash out shadow

Question 16

Early stage HCC treatment, what are the key factors that qualify for this?

Answer 16

Ablation - frying tumour with microwaves if tumour less than 3cm and in an accessible place

Can be curative

Question 17

If ablation is not possible, what can you try?

Answer 17

Surgical resection

Curative

Question 18

Who qualifies for surgical resection?

Answer 18

Good initial liver with Child-Pugh A
Future liver remnant (FLR)
No metastasis and no portal hypertension

As if not, they can decompensate and die

Question 19

Final option for HCC

Answer 19

Transplant if 5 year survival expected to be over 70%

Question 20

What criteria is used for liver transplant and what does this involve?

Answer 20

Milan criteria 
Up to 3 HCCs within 3 cm
Or 1 HCC within 5cm 
no extra-hepatic involvement
no major vessel involvement

Question 21

What is TACE?

Answer 21

Trans arterial chemo embolisation (TACE)

Question 22

If you can’t do ablation, resection, TACE or transplant, what would you give?

Answer 22

Systemic treatment e.g.
Sorafenib
Levantinib

Question 23

Explain TACE

Answer 23

Find feeding artery to HCC
Inject chemotherapy (Rubicin)
Block blood supply by injecting gel
Cause the blood supply to become ischemic

Question 24

Consequence of TACE

Answer 24

Post embolization syndrome

Question 25

What are the symptoms of post embolisation syndrome?

Answer 25

Fever
Abdo pain
AKI
Haematoma
Urinary retention
Pleural effusion
Thrombocytopenia
Pneumonia