Hepatocellular Cancer

Question 1

In which conditions can you develop HCC without cirrhosis?

Answer 1

Hep B

Fatty liver disease

Question 2

Medications for secondary prevention for HCC

Answer 2

Aspirin, statins, metformin = reduce risk of HCC

Question 3

Populations in whom HCC surveillance is required

Answer 3

6 monthly US + AFP

Populations in whom HCC surveillance is required

1. People with cirrhosis (any aetiology)
2. People with chronic Hep B without cirrhosis
   - Asian men >40yo
   - Asian women > 50yo
   - Sub-saharan Africans ?20 yo
   - Indigenous + Torres Strait Islander >50yo

Question 4

Populations in whom HCC surveillance is required

Answer 4

6 monthly US + AFP

Populations in whom HCC surveillance is required

1. People with cirrhosis (any aetiology)
2. People with chronic Hep B without cirrhosis
   - Asian men >40yo
   - Asian women > 50yo
   - Sub-saharan Africans ?20 yo
   - Indigenous + Torres Strait Islander >50yo

Question 5

Investigations for HCC/hepatic nodule

Answer 5

<1cm: repeat US at 4 month

> 1cm: multiphase contrast CT
- Arterial phase hyperenhancement
- Washout on portal and delayed phase
If positive on CT = HCC

If unsure - liver biopsy

Question 6

Management of HCC

Answer 6

• If no portal HTN= resect
• If within criteria = transplant
  Needs preserved liver fx, solitary nodule or 2-3 nodules <3cm + transplant candidate
• If not transplant candidate = locoregional therapy
  TACE - involves delivery of chemo + occlusion of arterial supply
  Transarterial Chemoembolization
  Local Ablation - radiofrequency ablation, microwave ablation
• If advanced/metastatic disease + Child Pugh A = atezolizumab + bevacizumab or sorafenib/levatinib
• If metastatic disease + Child Pugh B/C = palliate

Question 7

What does TACE involve

Answer 7

• Involves delivery of chemo + occlusion of arterial supply
• Can be used for larger tumours and on liver tx waiting list
• Considered palliative and not curative
• Chemotherapy - cisplastin or doxorubicin + lipidol

Question 8

What is the ECOG score

Answer 8

0 = Fully active; no performance restrictions.
1 = Strenuous physical activity restricted; fully ambulatory and able to carry out light work.
2 = Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about >50% of waking hours.
3 = Capable of only limited self-care; confined to bed or chair >50% of waking hours.
4 = Completely disabled; cannot carry out any self-care; totally confined to bed or chair.
5 = dead

Question 9

What is selective internal radiation therapy?

Answer 9

• Selectively target a very high radiation dose to all tumours within the liver, regardless of their cell of origin/location while at the same time maintaining a low radiation dose to the normal liver tissue
• Delivery via hepatic artery

Question 10

What are 3 first line treatment options for advanced HCC?

Answer 10

- Sorafenib: anti VEGF TKI 
(VEGFR, PDGFR, RAF kinases)
- Lenvatinib: anti VEGF TKI 
(VEGFR1, VEGFR2, VEGFR3)
- Atezolizumab + Bevacizumab 
Atezolizumab: anti-PDL1 monoclonal Ab
Bevacizumab: anti-VEGF monoclonal Ab

Question 11

SE of sorafenib and lenvatinib

Answer 11

Refractory htn
Diarrhoea
Hand foot syndrome

Question 12

Criteria for HCC and liver transplant

Answer 12

Milan Criteria

• Single tumour ≤ 5cm OR
• ≤ 3 nodules ≤ 3 cm

Expanded Criteria

• Single lesion ≤ 6.5cm
• ≤ 3 nodles, each ≤ 4.5cm
• Total tumour diameter ≤ 8cm

Portal hypertension is a contraindication for liver resection

Question 13

In Hep B, what is a risk factor for progression to HCC?

Answer 13

Elevated ALT