Workup/Staging Flashcards
What is the workup of suspected HCC?
Suspected HCC workup: H&P, AFP, CBC, CMP with LDH, LFTs, PT/INR, hepatitis panel (HBV/HCV studies), triphasic CT abdomen or MRI liver (late hepatic arterial, portal venous, and delayed phases), chest CT, and percutaneous Bx if necessary
For a pt with suspected HCC, when is a Bx unnecessary to establish the Dx?
In HCC, a Bx is not necessary to establish Dx if it has imaging characteristics consistent with HCC (e.g., liver imaging reporting and data system [LI-RADS] [most common], Organ Procurement and Transplantation Network [OPTN], American Association for the Study of Liver Diseases [AASLD]) based on factors including size, arterial phase hyperenhancement, venous phase washout appearance and capsule appearance, and threshold growth.
In what HCC variant is the AFP level often normal?
AFP levels are normal in the majority of pts with fibrolamellar carcinoma (FLC), a variant of HCC. Note that some authors argue that FLC is not truly a variant of HCC b/c it usually occurs in the absence of cirrhosis, and the better prognosis has been attributed to a lack of liver Dz as pts do not respond any differently to therapies vs. typical HCC. (Liu S et al., Am J Gastroenterol 2009)
What are the characteristic triphasic CT and MRI findings of an HCC liver lesion?
On dynamic CT: early phase, tumor is seen as hyperintense b/c of increased vascularity. In the delayed phase, the tumor is hypodense d/t contrast washout.
On MRI T1-weighted images: low-signal intensity and intermediate-signal intensity on T2; HCC appears hypervascular, has increased T2 signal, and shows venous invasion
What is the AJCC 8th edition (2017) TNM staging for HCC?
T1a: solitary tumor ≤2 cm
T1b: solitary tumor >2 cm without vascular invasion
T2: solitary tumor >2 cm with vascular invasion, or multiple tumors ≤5 cm
T3: multiple tumors, at least 1 of which is >5 cm
T4: Single tumor or multiple tumors of any size involving a major branch of the portal vein or hepatic vein, or tumor(s) with direct invasion of adjacent organs other than the gallbladder or with perforation of visceral peritoneum.
N1: regional LN mets (hilar, hepatoduodenal ligament, inf phrenic LN [no longer classified as M1], and caval LNs)
M1: DMs
What are the AJCC 8th edition (2017) stage groupings for HCC?
Stage IA: T1aN0
Stage IB: T1bN0
Stage II: T2N0
Stage IIIA: T3N0
Stage IIIB: T4N0
Stage IVA: Any T N1 M0
Stage IVB: Any T Any N M1
Name 3 systems (other than AJCC) used to stage HCC internationally.
Staging systems for HCC commonly used outside the United States: Applicability of each of these staging systems appears to depend on the Tx method.
- BCLC (Barcelona Clinic Liver Cancer)
- CLIP (Cancer of the Liver Italian Program)
- JIS score (Japanese Integrated Staging)
What does a Child–Pugh score predict in pts with chronic liver Dz?
The Child–Pugh score was originally used to estimate operative mortality risk but is currently used to assess OS prognosis for pts with liver failure. Based on cumulative scores, pts are divided into class A, B, or C, with C having the poorest prognosis.
What are the 5 components of the Child–Pugh score in chronic liver Dz?
Components of the Child–Pugh score include total bilirubin, serum albumin, INR, degree of ascites, and degree of hepatic encephalopathy.
What does the acronym MELD represent, and what does the MELD score predict in chronic liver Dz?
MELD stands for Model for End-Stage Liver Disease, initially developed to predict the 3-mo mortality after a transjugular intrahepatic portosystemic shunt procedure. Now, it is used to assess severity of chronic liver Dz and the 3-mo OS without a liver transplant. The MELD score is highly correlated with the Child–Pugh score.
What are the 3 components of the MELD score in chronic liver Dz?
Components of the MELD score include total bilirubin, INR, and Cr.
