hepatocellular carcinoma Flashcards
What is the diagnostic approach to determine if a patient has HCC
–AFP levels over 20 are concerning
– for US lesions get MRI/CT with liver specific protocol to further assess
–for lesions that are characteristic of HCC no biopsy is needed
–for lesions under 1 cm should repeat AFP and CT/MRI imaging to assess for progression on a Q3-6 mo basis
–for lesions over 1 cm without clear findings of HCC consider multi-D approach and possible biopsy of the lesion
What Staging systems are used for HCC
AJCC recommends TNM staging which is validated and better than clinical staging systems at predicting prognosis.
clinical staging systems including Okuda, Barcelona, and CLIP may be more helpful in patients with poor baseline liver function by Child’s Pugh score
T Staging breakdown
1a if under 2 cm
1b if over 2 cm without vascular invasion
2 if over 2 cm w/ vascular invasion or multiple tumors none over 5 cm
3 if multiple tumors w/ 1 at least over 5 cm
4 if tumor involves major branches of PV/HV or if tumor invades non gallbladder adjacent organs or if tumor perforates visceral peritoneum
TNM STAGING
Ia if T score of 1a
Ib if T score of 1b
II if T score of 2 with N0 and M0
IIIa if Tscore of 3 with N0, M0
IIIb if T score of 4 with N0,M0
IVa if T(any) but N1, M0
IVb if T(any), N(any) but M(1)
what is BCLC
Barcelona Clinic Liver Cancer which is a group of physicians that help to determine treatment algorithms for HCC
Definition/Treatment/Prognosis
for VERY EARLY STAGE HCC
defined as single lesion under 2 cm with ECOG of 0 and child’s pugh class A disease
Treatment options include resection if at all possible per NCCN guidelines with non-resectable lesions managed with ablation (Radiofrequency ablation, microwave ablation)
post ablation/resection treatment of Hep C and Hep B recommended
Prognosis is over 6 years median OS
Definition/Treatment/Prognosis for EARLY STAGE HCC
defined as single lesion or under 3 nodules all under 3 cm with child’s pugh class of A or B and ECOG of 0
For solitary lesions resection is preferred however transplant > ablations > TACE are also options
For multi-nodule disease transplant > ablations > TACE are options
prognosis is over 6 years median OS and over 10 years s/p Liver transplant
Definition/Treatment/Prognosis for INTERMEDIATE STAGE HCC
defined as multinodular disease meaning more than 3 nodules or multinodular with at least 1 nodule over 3 cm plus child’s pugh A-B, ECOG of 0
trans-arterial chemo-embolization plus or minus Atezolizumab + bevacizumab (PD-L1 ab/VEGF) 1st line vs sorafenib/lenvatinib (2nd line) vs regorafinib/cabozantinib/ramucirumab (3rd line)
prognosis over 30 months median OS
Definition/Treatment/Prognosis for ADVANCED STAGE HCC
defined as portal invasion, nodal or metastatic disease with a child’s pugh of A-B and ECOG of 1-2
Atezolizumab + bevacizumab (PD-L1 ab/VEGF) 1st line vs sorafenib/lenvatinib (2nd line) vs regorafinib/cabozantinib/ramucirumab (3rd line)
Prognosis of 8-17 months median OS comparing 1st and 3rd line therapies
TERMINAL STAGE HCC by BCLC
ecog over 3 or child’s pugh of C
supportive care
