Liver Cancer Flashcards
What is the indo-cyanine green test?
Correlates with MELD score.
RR of mortality for major hepatectomy increase 3x if ICG retention at 15 minutes >14%
What is the adequate future liver remnant percentage?
Normal liver: FLR of at least 25% to prevent postop liver failure
Cirrhotic liver: FLR up to at least 40% necessary
Inadequate FLR is the most common factor precluding curative LR
What is the Milan Criteria?
1) Single lesion, 5cm or less
2) No more than 3 nodules, each
Which is better in early HCC?
Liver Resection or Liver Transplant.
Why
Liver Transplant
- Better survival with liver transplant if HCC within Milan criteria
- Lower recurrence rate, but poorer long-term outcome
What is the 5-yr OS in liver transplant for HCC?
N=4500
Pelletier 2009
5yr OS within Milan 65%
5yr OS outside Milan 40%
Describe RFA
1) Most efficacious for small volume HCC (No more than 3 lesions, each no more than 3cm)
2) 5yr OS 30-60%
3) risk of Mortality 1%, Complx risk 3-7%
4) No diff in OS & DFS compared to resection. Less Complx with RFA
5) RFA superior to PEI in RR, OS, RFS
Describe TACE
TACE = Trans-arterial Chemoembolisation
1st line Tx for unrest table, large/multi focal HCC w/o vascular invasion/etrahepatic spread
Can be used prior to resection/bridging therapy prior to transplant
Doxorubicin/CDDP
CR 2%, Disease control rate 40%.
ORR 20-60%
What is the post-embolization syndrome?
~90% following TACE.
Fever, malaise, RUQ pain, nausea+vomiting
Contra-indications to TACE
Absolute:
- Thrombus in main portal vein and portal vein obstruction (high risk of liver failure)
- Encephalopathy
- Biliary Obstruction
- CP score C
Relative:
- BIL >34
- LDH >425
- AST >100
- Tumor burden >50% of liver
- Cardiac/renal insufficiency
- Ascites, recent variceal bleed, significant thrombocytopenia
- Transjugular inhtrahepatic portosystmic shunt (TIPS)
Conventional TACE vs DCBeads TACE
PRECISION V Trial
- Phase II, n=200
- TACE (Doxorubicin) vs DC Beads (Doxorubicin)
- non-significant results. Trend towards improved RR and disease control rate
- Significant: Less liver toxicity, less Doxorubicin toxicity with DC beads
What is the role of combining Sorafenib + TACE in intermediate HCC?
SPACE (Sorafenib or Placebo in combination with TACE in HCC)
Phase II, RCT, 2 arms:
- DC TACE + SORAFENIB
- DC TACE + Placebo
Incl criteria:
- unrest table HCC
Role of Chemoimmunotherapy in HCC
- using PIAF regimen
PIAF = CDDP, Doxorubicin, IFNa, CI 5FU
- Phase III compared PIAF to doxorubicin.
- n=200
- RR 20% vs 10%, not significant. No CRs
- Med Survival 8.7m vs 7m
- Sig more toxicities: 80% neutropenia, 60% thrombocytopenia
What is the EACH study?
Phase III, RCT, n=370. 2 arms:
- FOLFOX4 vs Doxorubicin group
Role of XELOX in HCC?
Phase II study, n=50
ORR 6%, DCR 70%
Med OS 9.3m
Describe the SHARP trial
Llovet NEJM 2008
N=300
Advanced HCC, CPA, ECOG 0-2, Life expectancy at least 12 months
Randomized to Sorafenib vs Placebo
RR 2%vs 1%
TTP 5.5 m vs 3m
0S 10.7m vs 8
Describe the Asia-Pacific study
Advanced HCC, ECOG 0-2, CP A
2 groups: Sorafenib vs placebo
-N=226
RR 3% vs 1%
TTP: 3m vs 1.5 m
OS 6.5m vs 4m
Side-effects of Sorafenib
Diarrhea
HFS
Fatigue
Rash
Any Role for Adjuvant Therapy in HCC?
No!
STORM trial was negative.
N=1100
Sorafenib as adjuvant tx in prevention of Recurrence of HCC
Prior tx of:
- Resection
- RFA
- PEI
In Whom is HCC Screening & Surveillance is Recommended?
1) Hepatitis B Carriers (HBsAg +)
- Asian males >40yo; Females >50yo
- All cirrhotic Hep B carriers
- FHx of HCC
- Africans >20yo
2) Non-Hep B Cirrhosis
- Hep C
- Alcoholic Cirrhosis
- Genetic hemochromatosis
- Primary Biliary Cirrhosis
- possibly: AAT deficiency, NASH, Autoimmune hepatitis
Name some Staging systems for HCC
1) Okuda Staging
2) Child-Turcotte-Pugh (for cirrhosis)
3) BCLC staging
4) CLIP staging (Cancer of the Liver Italian Program)
5) CUPI
Describe the Okuda Staging
Uses Tumor size, presence of Ascites, Bilirubin and serum Albumin
Stage I: No + factors
Stage II: 1-2 positive factors
stage III: 3-4 positive factors
Describe the CLIP Staging.
- Cancer of the Liver Italian Program
1) Components:
- Child-Pugh Score,
- Tumor morphology and % of involvement of liver
- AFP
- Portal Vein thrombosis
Does not adequately assess those undergoing radical therapies (eg. Resection/transplantation)
Describe HBV cancer-promoting actions:
1) Insertional mutagenesis
2) p3 inhibition
- explains why it can induce HCC in non-cirrhotic liver
What are the variables that affect risk of recurrence following resection of HCC?
1) Tumor size
2) Number of tumors
3) Vascular invasion
4) Width of resection margin
What are the methods of Percutaneous Ablation for HCC?
1) Percutaneous Ethanol Injectino
2) RFA
3) Injection of acetic acid
4) Injection of boiling saline
5) Cryotherapy
6) Microwave therapy
7) Laser therapy
Usage of TACE is limited to what group of patients?
Preserved liver function
Absence of extra hepatic spread
Absence of vascular invasion
No significant cancer-related symptoms
TACE may offer palliative benefits for patients with intermediate stage HCC, with 5-yr survival rates > 50%
Explain TACE
TACE = Transarterial Chemoembolization
Induce ischemic tumor necrosis via acute arterial occlusion
Emboli station may be done alone (Transarterial embolization) or combined with selective intraarterial chemotherapy (TACE)
What are the factors in the CUPI score?
CUPI = Chinese University Prognostic score
(A.A.A.A.T.T)
Variables include:
1) TNM stage
2) Asymptomatic disease on presentation
3) Ascites
4) AFP
5) Total bilirubin
6) ALP
What are the factors in Okuda staging
1) Tumor Size
2) Ascites
3) Albumin
4) Bilirubin
What are the risk factors for HCC?
Hep B, C Alcohol Genetic hemochromatosis NASH Stage 4 primary biliary cirrhosis Alpha1-anti trypsin deficiency Other causes of cirrhosis
What are the risk factors for HCC?
Hep B, C Alcohol Genetic hemochromatosis NASH Stage 4 primary biliary cirrhosis Alpha1-anti trypsin deficiency Other causes of cirrhosis
What are the risk factors for HCC?
Hep B, C Alcohol Genetic hemochromatosis NASH Stage 4 primary biliary cirrhosis Alpha1-anti trypsin deficiency Other causes of cirrhosis
