Hepatobiliary Surgery JC064: A Large Liver: Liver Cancer Flashcards

1
Q

***Hepatomegaly DDx

A

Malignant:
Primary
1. **HCC (most common)
2. **
Cholangiocarcinoma
3. Others (e.g. Lymphoma)

***Secondary
1. GI tract
2. Other primary (Breast, Lung)

***Haematological
1. Lymphoma
2. Leukaemia
3. Myeloproliferative disease

Benign:
Benign tumours
1. **Haemangioma
2. **
Adenoma
3. Focal nodular hyperplasia

Cyst
1. Simple cyst
2. ***Polycystic disease

Others
1. **Alcoholic cirrhosis
2. **
Liver abscess

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2
Q

History taking of Hepatomegaly

A
  1. ***Pain (site, onset, duration)
  2. ***Tea-colour urine (Jaundice)
  3. N+V
  4. Bowel changes
  5. Systemic review: any symptoms suggestive of other primary malignancy
  6. Constitutional symptoms: LOW, LOA, malaise
  7. ***Past history of HBsAg carrier, Hep C, Liver disease
  8. Social history: ***Alcohol
  9. Family history of malignancy
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3
Q

Physical examination of Hepatomegaly

A

General:
1. Pallor
2. **Jaundice
3. **
Lymphadenopathy
4. ***Stigmata of chronic liver disease
5. Cachexia

Abdomen:
1. Hepatomegaly
- **size (cm below costal margin)
- tenderness
- **
consistency (hard, firm, soft)
- **surface (nodular)
—> Smooth: Fatty liver, alcoholic cirrhosis, primary biliary cholangitis
—> Nodular: Polycystic kidney and liver disease
—> Large nodules: HCC
- edge
- **
bruit (suggest vascular tumour e.g. HCC)
—> Vascular tumour (e.g. HCC) —> heard all over
—> Alcoholic hepatitis —> heard all over
—> Compression of aorta —> turn patient to right side and bruit less prominent

  1. Other organomegaly
    - Splenomegaly: **Portal hypertension, **Haematological malignancy
  2. Mass
  3. ***Ascites
  4. PR exam

Other systems

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4
Q

***Characteristics of Hepatomegaly

A

Diffuse smooth firm Hepatomegaly:
- Alcoholic liver disease
- Haematological malignancies (∵ diffuse infiltrative process)

Irregular hard Hepatomegaly (likely to be solid tumours):
- HCC
- Cholangiocarcinoma
- Secondary malignancies

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5
Q

***Investigations of Hepatomegaly

A

Blood tests
1. CBC
- e.g. **thrombocytopenia: ∵ hypersplenism in cirrhosis
- **
abnormal WBC: haematological malignancies

  1. Coagulation profile
    - e.g. ***prolonged INR in cirrhosis
  2. LFT
    - clue to chronic hepatitis / cirrhosis
  3. Viral hepatitis serology
    - **HBsAg
    - **
    Anti-HCV Ab
  4. Tumour markers
    - **AFP: HCC, Embryonal carcinoma, Yolk sac tumour
    - **
    CEA: Cholangiocarcinoma, CRC
    - **CA 19.9: Cholangiocarcinoma, GI malignancies (e.g. **Pancreatic CA)
    —> Help but NOT diagnostic
    —> NOT all patients have ↑ tumour markers, mildly ↑ tumour markers can occur in benign conditions

Imaging
1. CXR (primary lung cancer, cannon ball lesions)

  1. USG (**1st line)
    - whether a mass
    - confirm whether hepatomegaly
    - cirrhosis
    - **
    splenomegaly
    - tumours in pancreas
  2. CT (***Contrast)
  3. MRI
    - more phases, accuracies generally higher than CT
  4. PET-CT
    - confirm primary tumour + detect metastasis in other organs

Endoscopy (for suspected primary GI malignancy)
1. Upper endoscopy
2. Colonoscopy

Biopsy
1. USG-guided percutaneous **FNAC
2. **
Trucut core biopsy
- 1-2% bleeding risk
- 1-2% chance percutaneous needle tract seeding
—> **NOT advocate biopsy for all patients if well-established cancer + resectable (will do surgical resection + pathology instead)
—> only useful in patients with **
advanced malignancy beyond surgery (chemotherapy + histopathology to establish nature)

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6
Q

Management of Hepatomegaly

A

Depends on underlying pathology
- Surgical / Non-surgical

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7
Q

Hepatocellular Carcinoma (HCC)

A

Causes:
1. ***HBV (80% of HCC)
2. HCV (common in japan, western)
3. Cirrhosis (Alcoholic and other types)
4. Alflatoxin (fungal derivatives, ↑ chance of HCC esp. in HBV carrier, in peanuts not probably stored, contaminated by mould)

3 pathological / macroscopic types:
1. Massive (i.e. big mass)
2. Diffuse (i.e. infiltrative)
3. Nodular (i.e. multiple small nodules)
4. Fibrolamellar HCC (very rare histological variant, in young females, in western mainly, good prognosis)

Pathology:
- **Rapid tumour growth (double size in 3-4 months)
- **
Venous invasion tendency (portal vein / hepatic vein)
- **Intrahepatic metastasis to rest of liver (via **portal venous circulation)
- **Lung metastasis (via hepatic vein dissemination)
- **
Peritoneal metastasis
- frequency association with cirrhosis (80% in HK)

Incidence:
- 1800 new cases per year
- commonest primary liver cancer
- 2rd commonest cancer deaths
- 5th commonest cancer incidence
- ***M:F = 4:1
- mostly >50 yo (but can occur in young patient)

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8
Q

***Clinical features of HCC

A
  1. Subclinical
    - liver relatively insensitive organ, large tumour can be asymptomatic, usually in HBV carrier who perform regular imaging surveillance —> incidental findings
    - screening with **AFP, **USG in HBsAg carrier / cirrhotic patients
  2. RUQ / Epigastric pain
    - can be mistaken as peptic disease
  3. Hepatomegaly
    - abnormal mass felt in upper abdomen
  4. LOA, LOW, malaise
  5. ***Decompensation of cirrhosis
    - Child-Pugh A suddenly develop ascites, variceal bleeding, hepatic encephalopathy
    - NB: HCC may also occur in patients without cirrhosis!
  6. ***Tumour rupture
    - rare, intraperitoneal haemorrhage, acute abdominal pain, shock
  7. Paraneoplastic features
    - rare, e.g. **polycythaemia, refractory diarrhoea, **fever of unknown origin, **hypercalcaemia, **hypoglycaemia
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9
Q

***Diagnosis of HCC

A

One of cancers that no need histological diagnosis
1. ↑ AFP ***>400 ng/mL (quite specific)
- AFP normal (<20) in 30% HCC
- can be ↑ in chronic hepatitis / cirrhosis esp. with active viral replications (high HBV DNA in blood)

  1. Imaging
    - USG
  • CT scan (typical appearance)
    —> Non-contrast phase: hypodense
    —> Arterial phase / Contrast phase (1st 30 seconds, contrast still in arterial system): **
    hyperdense (tumour takes up blood mainly from hepatic artery instead of portal vein, on CT scan: compare with aorta (
    hyperdense aorta —> arterial phase))
    —> Portal venous phase: **
    hypodense (washout) (compared to parenchyma ∵ surrounding liver has more blood supply from portal vein)
    (NB: other cancers e.g. Cholangiocarcinoma / Secondary malignancy: arterial phase: ***hypodense instead (exact reverse))
  • Post-Lipiodol CT (lipiodol injected via arteriography, repeat CT in 2 weeks for uptake by tumour, for uncertain cases after CT + Hepatic arteriography)
  • MRI (alternative to CT, may also be useful in uncertain cases after CT)
  • Hepatic arteriography (past, typical neovascularisation, for uncertain cases after CT)
  • **PET scan (2 phases: **FDG + ***C-11 acetate) (FDG alone can miss HCC up to 50%)
  1. Biopsy (only for inoperable cases / very uncertain imaging results)
    - FNAC
    - Trucut biopsy
  2. Indocyanine (ICG) clearance test
    - a special dye excreted solely by liver
    - best test for ***liver function reserve if planning for surgical resection
    - ICG retention at 15 mins of <14% —> Adequate liver function
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10
Q

***Surgical treatment of HCC

A
  1. Hepatic resection
    - 20% HCC resectable
    —> **Unilobar
    —> **
    Absence of main portal vein invasion
    —> **Absence of distant metastasis
    —> **
    Adequate liver function (ICG retention at 15 mins of <14%)
    - 5 year survival rate >50%
    - operative mortality rate 1-5%
    - recurrence **50% (mainly in liver remnant due to **intrahepatic metastasis via portal vein / multicentric tumours, need regular 3-monthly surveillance with AFP, CT, early detection of recurrence —> re-resection / TOCE / ethanol injection)
  2. Liver transplantation (one of few solid tumours that can be treated by transplantation)
    - HCC **<5-6.5cm (i.e. **Early HCC) (5cm: Milan criteria, 6.5cm: UCSF criteria)
    - **no macroscopic venous invasion / distant metastasis
    - **
    Child B/C cirrhosis (∵ may not be good candidate for surgery due to poor LFT)
    - 5-year survival rate 70-80%
    - immunosuppressants may ↑ recurrence chance, ∴ not for advanced cancers
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11
Q

***Locoregional treatment of HCC

A

Embolisation
1. Transarterial oily chemoembolisation (TACE / TOCE) / Radioembolisation
- Local Chemotherapy + Embolisation
—> **Lipiodol (selectively taken up by HCC, unknown reasons)
+
—> **
Cisplatin / Doxorubicin
+
—> **Gelfoam (block arterial supply of tumour —> slow down growth)
- bilobar / unilobar **
unresectable tumours, reasonable liver function (bilirubin **<50), absence of main **portal vein thrombosis / distant metastasis
- **1st choice if **ruptured HCC (if still uncontrolled bleeding —> laparotomy)
- response rate: 30-40%
- continue once every 2-3 months

Ablation treatment (chemical / energy)
2. Percutaneous ethanol injection
- USG-guided for **<=3 tumours of **<=3-5 cm

  1. Cryotherapy
  2. Microwave / Radiofrequency thermoablation (**RFA)
    - for tumours **
    <5 cm, ***<4 nodules
    - outcome ~ surgical resection
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12
Q

Non-surgical Palliative treatment

A
  • for Metastasis to other organs
  • Overall response rate: only 15-25%
  1. Chemotherapy (e.g. doxorubicin), Tamoxifen, IFN
    - not proven to be effective (∵ HCC is a ***chemo-resistant cancer + poor LFT cannot tolerate chemo well)
  2. External radiotherapy
    - stereotactic body radiation therapy (SBRT)
    - benefit limited for large tumours
  3. Targeted therapy (***Sorafenib, Lenvatinib)
    - prolong survival by 3-4 months
  4. ***Anti-PD1 immunotherapy (Nivolumab)
    - modulate immune cells to kill cancer cells
    - response ~20%
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13
Q

Distribution of treatment in HCC

A

100 HCC patient:
- 20 Surgery
- 15 RFA
- <5 Liver transplantation (∵ only suitable for ***early HCC + scarce supply of organs)
- 20 TACE
- 35 Systemic treatment

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14
Q

Long-term survival rate of HCC

A

5-year survival rate
- **Partial hepatectomy: 60%
- **
Transplantation: 75%
- ***RFA: 50%
- TACE: 15%
- Systemic therapy: <5%

Advanced HCC with supportive treatment: 2-4 months

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15
Q

Cholangiocarcinoma

A
  • 5-20% of primary liver cancer
  • ***Adenocarcinoma of bile duct
  • > 50 yo

Causes:
- no exact known cause
- associated with
—> **HBV carrier
—> **
RPC (common in chinese)
—> ***PSC
—> Ulcerative colitis (rare in chinese)

2 types:
- Intrahepatic Cholangiocarcinoma (~ HCC, present as a mass)
- Extrahepatic Cholangiocarcinoma (present as strictures —> **Jaundice)
—> **
different presentation

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16
Q

Clinical features of Cholangiocarcinoma

A
  1. RUQ pain
  2. ***Hepatomegaly
  3. ***Jaundice (depend on location, e.g. near liver hilum)
  4. LOA, LOW, fever
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17
Q

Diagnosis of Cholangiocarcinoma

A

Tumour markers (may be ↑):
1. CEA (carcinoembryonic antigen)
2. CA 19.9

Imaging:
1. USG
2. CT
- hypodense in arterial phase (can be difficult to differentiate from secondary metastasis, must also do other imaging e.g. PET)
3. MRI
4. FDG-PET (no need dual tracer)
5. ***ERCP (can do stenting)

Biopsy (only for unresectable cases):
1. FNAC
2. Trucut

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18
Q

Treatment of Cholangiocarcinoma

A
  1. Surgical resection
    - treatment of choice
    - resectability 20%
    - **Bile duct excision + **Hepatectomy + ***Hilar LN clearance (important for staging) + Bile duct reconstruction
  2. Palliative systemic chemotherapy (Cholangiocarcinoma ***more sensitive to chemo than HCC) + RT (for unresectable cases)
    - targeted therapy little role
19
Q

Metastatic cancer to Liver

A
  • ***more common than primary liver cancer
  • 2nd most common site of metastasis (lung most common)
  • commonest site of metastasis for ***GI primary (∵ all blood supply from abdominal visceral organs go through portal vein through liver first)

Commonest site of Primary:
1. **Colon
2. **
Stomach
3. **Pancreas
4. **
Biliary tree

Other common sites of Primary:
1. Lung
2. Kidney
3. Breast
4. Gynaecological tract

20
Q

Clinical features of Metastatic cancer to Liver

A
  1. Known primary with Hepatomegaly
  2. Hepatomegaly / RUQ pain without symptoms referable to primary
  3. Constitutional symptoms: LOA, LOW, cachexia
  4. Ascites (suggest peritoneal seedling from GI / gynaecological primary)
21
Q

Diagnosis of Metastatic cancer to Liver

A

Tumour markers
1. CEA
2. CA 19.9

Imaging
1. USG
2. CT
3. MRI
4. PET

Biopsy (only for unresectable cases)
1. FNAC
2. Trucut
—> differentiate primary from secondary using ***immunostaining —> can tell origin

***Investigations for Primary
1. CXR (lung)
2. CT thorax (lung, breast)
3. Endoscopy (GI primary)

22
Q

Surgical treatment of Metastatic cancer to Liver

A

Hepatic resection
- **can be curative + prolong survival in patients with resectable **colorectal metastasis
- solitary / <=4 metastasis all within 1 lobe
—> 5-year survival 40%
—> 5-year disease-free survival 30%
—> 1/3 recurrence in liver remnant

  • may be useful for palliation of symptoms from **carcinoid / **neuroendocrine tumours (∵ prolong survival + stop secretion of vasoactive peptides —> prevent symptoms e.g. flushing, diarrhoea)
  • other metastasis suitable: **breast, **kidney, ***ovarian
  • generally NOT indicated in metastasis from **pancreas, **lungs, ***stomach (∵ usually are widespread metastasis, very poor prognosis —> systemic chemotherapy instead)
23
Q

Non-surgical treatment of Metastatic cancer to Liver

A
  1. Local ablative therapy e.g. ***RFA, SBRT
  2. Chemotherapy
    - depends on response of type of tumour
    - systemic / transarterial with colorectal metastasis (response 20-30%)
  3. Transarterial embolisation
    - generally not used for metastatic cancer except for ***neuroendocrine tumours which have good respond to TACE (for palliation)
24
Q

SpC Interactive tutorial: Advanced liver surgery for HBP malignancy

A

Screening for HCC:
1. HBV / HCV carriers
2. Cirrhosis
3. Family history of HCC

Methods:
1. USG
2. AFP, LFT
- every 6-12 months
- 90% detection rate

(HCC doubling time: 3 months)

25
Q

Evolution of HCC treatment

A
  1. Open to Laparoscopic liver resection —> Early tumours: Minimally invasive approach
  2. Improvement in open surgical techniques due to development of living donor liver transplantation —> Advanced tumours: Transplantation techniques, Complement resections
26
Q

Evolution of surgical techniques in liver transplantation

A

Resection techniques:
1. Anterior approach
2. Use of automatic vascular staplers
3. Use of energy device (Thunderbeat, Harmonic-ace)

Living donor liver transplantation techniques:
1. Control of IVC (isolate liver from IVC)
2. Venoplasty techniques (joining 2 veins together)
3. Haemodynamic control under IVC clamping without veno-venous bypass (important role by anaesthetist)
4. Parenchymal transection with patent inflow (living donor hepatectomy)
5. Understanding of small for size graft (i.e. partial graft) for recipient / remnant liver for donor

27
Q

2-stage hepatectomy

A

ALPPS: Associating Liver Partition and Portal vein Ligation for Staged hepatectomy

Indication
Major liver resection but ***insufficient future liver remnant (future liver remnant FLR <30%) (i.e. resection >= 3 Couinaud segments)

  1. Ligate right portal vein —> allow blood shunted to left liver —> left liver hypertrophy (in 7 days)
  2. Remove right liver
28
Q

SpC Interactive tutorial: HCC
Etiology of HCC

A
  1. ***Hep B (80% of HCC in HK)
  2. Hep C (predominant in Japan)
  3. ***Cirrhosis
  4. ***Aflatoxin (fungi: misstorage of food)

HBV
—(10 years if not cleared)—> Chronic hepatitis
—(20 years)—> Cirrhosis
—(20-30 years (Cirrhotic nodule —> Dysplastic nodule))—> HCC
or
HBV —> HCC

Epidemiology:
- Peak age: 50-70
- M»F

29
Q

Pathology of HCC

A

Macroscopic appearance:
1. **Massive type
- in **
non-cirrhotic liver
- in **younger age group
- **
large tumour with adjoining nodules
- variegated cut surface

  1. **Nodular type
    - multiple greyish white, yellow / brown nodules in cirrhotic liver
    - follow sequence of regeneration nodules —> dysplastic nodules —> **
    cirrhosis
  2. Diffuse type
    - least common
    - indistinguishable from cirrhosis
    - more associated with HCV pathway
30
Q

Spread of HCC

A
  1. Local invasion
    - **Portal vein (Intrahepatic metastasis: spread to adjacent segment / contralateral lobe —> surgery resection need to resect all downstream liver segments)
    - **
    Hepatic vein
    - ***Bile duct
  2. Lymphatic spread
    - 1/4 of patients
  3. Transperitoneal spread
    - Rare
  4. Haematogenous spread
    - Lung
    - Bone
31
Q

Clinical features of HCC

A

Tumour:
1. Subclinical (majority)
2. **Vague epigastric distension
3. Abdominal mass (usually 10cm before can be felt (stage T3: >5cm))
4. **
Paraneoplastic syndrome
- Diarrhoea (vasoactive intestinal peptide)
- Hypoglycaemia (impaired gluconeogenesis)
- Hyperglycaemia (impaired glycogenesis)
- Hypercalcaemia (PTH-rP)
- Polycythaemia (Erythropoietin)
5. Weight loss

Cirrhosis:
6. **Ascites (∵ decompensated cirrhosis / occlusion of portal vein by tumour thrombus / external tumour compression)
7. **
GI bleeding (variceal bleeding from cirrhosis portal hypertension, stress ulcer formation due to portal vein tumour thrombosis)

Complications:
8. **Secondaries in lung, bone (e.g. cough, bone pain, but usually detected by PET scan)
9. **
Sharp pain due to bleeding (Tumour rupture)

32
Q

***HCC Treatment

A

Surgical treatment:
1. Partial hepatectomy
2. Liver transplantation (after total hepatectomy)

Locoregional treatment:
3. Local ablative therapy (RFA / Microwave) (realisable, predictable, repeatable) (still Curative intent)
4. Transarterial oily chemoembolisation (TACE) (2nd line)
5. Percutaneous intralesional alcohol injection (largely replaced by Local ablative therapy)

33
Q

Pre-op assessment / Investigations of HCC

A
  1. Patient factor: **General status
    - Age (not a CI to surgery)
    - Concomitant medical disease
    - Hidden medical disease (e.g. CVS disease)
    —> **
    ECG, Spirometry, Astrup (ABG), Glucose, RFT etc.
    —> Aim to define whether the patient is fit for GA
  2. Patient factor: **Liver function status
    - Clinical examination (signs of liver decompensation)
    - Liver biochemistry (Albumin, Bilirubin)
    - PT
    - Platelet
    - **
    Child-Pugh classification (anything beyond Child A —> risky for major liver resection)
    - ***ICG clearance test (>14% remaining after 15 mins —> cannot tolerate major liver resection)
    —> Aim to define whether liver function is sufficient for the patient to tolerate hepatectomy
  3. Disease factor: ***Tumour status
    - USG (only for screening)
    - CT (provide better spatial resolution than MRI, ∵ short scanning time —> no need to hold breath)
    - MRI
    - +/- Hepatic arteriography (Angiography, obsolete, ∵ invasive, replaced by CT angiogram)
    - CXR (lung metastasis)
    - PET scan (FDG + C-11 acetate)
    —> Aim to define whether tumour still confined to one side of liver / whether technically feasible to resect / classify tumour, study anatomy before planning of surgery
  4. Surgeon factor

Surgery (Laparoscopy / Laparotomy) can be done if:
1. General condition is good
2. Liver function is satisfactory
3. Tumour is confined to one lobe

34
Q

PET-CT

A

FDG:
- longer t1/2, easier to prepare
- good accuracy in CRC but poor sensitivity in HCC (∵ different cell type: well differentiated / moderately differentiated / poorly differentiated HCC —> only poorly differentiated is easily detected by FDG)

C-11 acetate:
- short t1/2 (~30 mins), harder to prepare
- high sensitivity

35
Q

***Staging of HCC

A

Stage 1: <2cm
Stage 2: 2-5cm
Stage 3: >5cm
Stage 4: Extrahepatic spread

36
Q
  1. Partial hepatectomy
A

Indications:
1. **Unilobar involvement
2. **
No invasion into IVC / Portal vein
3. Acceptable liver function for major hepatectomy
- **Child A
- **
ICG retention 15 min <14%
4. No severe chronic medical illness

  • Mortality rate 5%
  • Morbidity rate 30%
  • Hepatectomy can offer cure and is associated with a 5-year survival of 50%
37
Q

Sites of recurrence of HCC after hepatectomy

A
  1. Liver remnant (80%)
  2. Extra-hepatic (50%)
  3. Both (5-10%)
38
Q

Laparoscopic liver resection

A

Now mainstream in small HCC
1. Pneumoperitoneum can compress on surface of hepatic vein —> less bleeding
2. New instruments for liver resection —> Clips and staplers
3. Laparoscopic CUSA
4. High definition monitor

Result:
- Less bleeding
- Comparable survival to open resection

39
Q
  1. Liver transplantation
A

Treat both HCC + Cirrhosis at the same time

Indications:
1. Tumour <5cm single / <3cm up to 3 nodules (**Milan criteria)
2. **
Child C cirrhosis

40
Q
  1. Local ablative therapy (RFA / Microwave)
A

Indications:
1. **Tumour <5cm
2. Satisfactory liver function reserve
3. **
CI to Laparoscopic / Open approach for HCC near to viscera

  • Localised thermal treatment technique (Percutaneous / Open approach)
  • RFA / Microwave (HIFU)
  • Replacing Percutaneous intralesional alcohol injection
  • Heating tumour cells to 45-50oC for >3 mins causes ***protein denaturation + irreversible cell damage
  • Induces tumour destruction by heating tumour tissue to temp >60oC
    —> if up to ~70oC —> soot formation —> insulator of heat —> prevent dissipation of heat
    —> Cool-tip RF system using disposable electrodes (17G)
  • USG / CT-guidance for introduction of electrodes + monitoring of ablation process

HIFU:
- ~Magnifying glass
- Oscillatory energy at focal point —> Coagulation necrosis
- USG energy transmitted through high density medium (e.g. water) —> patient put in waterbath

RFA vs HIFU:
- Similar effectiveness + survival benefit

RFA:
- Adhesion in subsequent operation
- Needle track
- ***CI in patients with ascites
- Ablation volume not as precise

HIFU:
- No adhesion in subsequent operation
- No needle track
- ***Favourable in patients with ascites
- Precise localisation, little collateral damage

41
Q
  1. Transarterial oily chemoembolisation (TACE)
A

Purpose:
1. ***Palliative intention (TACE cannot kill all cancer cells)
2. Augment liver remnant for future hepatectomy

Indications:
1. **Bilobar involvement without distant spread, without complete portal vein obstruction / IVC involvement
2. **
Unilobar involvement but liver function not acceptable for hepatectomy / RFA

Puncture femoral artery
—> Catheter into hepatic artery
—> Cisplatin + Lipiodol emulsion mixture to tumour (cell membrane of tumour absorb Lipiodol —> take in Cisplatin)
—> Block feeding vessel by Gelfoam (block blood supply —> ischaemia)

Complications (Felix Lai):
1. Post-embolisation syndrome (most common) (60-80%)
- Due to hepatocytes + tumour necrosis and ischemic damage to normal liver parenchyma
- Fever, N+V, abdominal pain, deranged LFT with ↑ AST/ALT (2:1) transiently for **1-2 days
- Full recovery is typically within 7-10 days
- Cover with antibiotics but should perform USG to exclude **
liver abscess if symptoms persist for 1 week

  1. **Liver failure (Hepatic decompensation) (most serious) (20-30%)
    - Treatment-induced ischemic damage to non-tumour bearing liver is responsible for precipitating or exacerbating liver failure
    - Usually reversible but it may be irreversible in 2% of cases
    - Clinically suspected by ↑ **
    bilirubin + ↑ ***PT (INR)
  2. Ischaemic ulceration (due to disturbed GI blood supply)
    - Gastritis / Cholecystitis / Pancreatitis
    - ***Acalculous cholecystitis due to damage to the cholecystic artery
42
Q
  1. Percutaneous intralesional alcohol injection
A

Indications:
1. **Tumour <3cm
2. **
Tumour number <3

  • Need to ***repeat 3-5 times before see effect
  • Ethanol induce **dehydration + **coagulation necrosis of cancer cells —> fibrotic degeneration
43
Q

Systemic therapy

A

Previously used:
1. Chemotherapy (Doxorubicin)
2. Hormonal therapy (Tamoxifen, Octreotide)
3. Immunotherapy (IFN)
- None proven to give survival benefit

Current:
1. ***Sorafenib (Molecular targeting drug: RAF kinase + VEGF receptor)
- currently only approved drug for HCC
- prolong survival for 3 months in clinical trials

  1. ***Anti-PD1 / PDL1
    - new in 2020
44
Q

Ruptured HCC management

A

Suspicion of HCC rupture (abdominal pain, pallor, history of Hep B/C, history of HCC, screening USG result)
—> Diagnosis of HCC rupture by **contrast CT
—> No ongoing blood loss —> **
Conservative management
—> Ongoing blood loss
—> Haemodynamically unstable for TACE (TAE?) —> **Surgical intervention
—> Haemodynamically stable for TACE (TAE?)
—> **
TACE (TAE?) —> Successful haemostasis —> Work-up for definitive treatment
—> Unsuccessful haemostasis —> ***Surgical intervention

Surgical intervention:
1. **Ligation of hepatic artery (associated with risk of liver failure) + Hepatectomy
2. **
RFA in open approach (stop bleeding by coagulation + treat cancer) —> less risky in a shock patient + much better survival