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IR Oncology > Y90 HCC > Flashcards

Y90 HCC Flashcards

1
Q

Why is complete pathological necrosis important for HCC Y90

A
  • tumors with CPN had lower HCC recurrence rate than tumors with incomplete necrosis
  • CPN has lower HCC-related mortality, recurrence free survival, and longer time to recurrence

https://pubmed.ncbi.nlm.nih.gov/32749512/

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2
Q

Target dose per LEGACY trial for HCC segmental Y90 infusion

A

> 400 Gy

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3
Q

how many segments are in a radiation segmentectomy

A

2 segments or less

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4
Q

check list of vessels to watch for in MAA mapping

A
  1. GDA
  2. cystic
  3. Right gastric artery
  4. gastrohepatic trunk
  5. falciform
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5
Q

characteristic appearance of the cystic artery

A

inverted Y or “forked tongue” appearance

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6
Q

mesenteric angiography power injections times for

  1. proximal anatomical delineation
  2. parenchymal background
  3. venous outflow
A
  1. 0-2 seconds
  2. 2-10 seconds
  3. 10-20 seconds
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7
Q

tumor size and liver volume percentage radiation major hepatectomy is performed

A

Patients with HCC 5 cm or larger, greater than 60% of the total liver volume

https://learn.sirweb.org/pluginfile.php/61503/block_html/content/Feb%202024%20JVIR%20article.pdf

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8
Q

what is the Future liver remnant per Nontumor liver volume radiation major hepatectomy be performed

A

FLR/NTLV has to be greater than 30%

https://learn.sirweb.org/pluginfile.php/61503/block_html/content/Feb%202024%20JVIR%20article.pdf

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9
Q

according to the IFU for theraspheres, what is the maximum dose that is recommended to the total liver volume

A

150Gy per whole liver

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10
Q

what is the standard definition of major hepatectomy

A

resection of 4 or more liver segments

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11
Q

other than a FLR/NTLV of greater than 30%, what other criteria were listed for performing radiation major hepatectomy

A
  1. Child-Pugh Class A
  2. ECOG 0
  3. no vascular invasion
  4. less than 5 tumors
  5. no evidence of extrahepatic spread
  6. no tumor in the FLR
  7. estimated lung dose <30Gy while achieving >150Gy in the perfused volume

https://learn.sirweb.org/pluginfile.php/61503/block_html/content/Feb%202024%20JVIR%20article.pdf

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12
Q

lung dose threshold has to be less than what

A

less than 30 Gy

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13
Q

Epidemiology of liver cancer - how common is it worldwide and where does it rank in cancer-related deaths?

A

6th most common cancer worldwide
3rd leading cause of cancer related deaths world wide and in the US

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14
Q

what is the strongest risk factor for developing HCC

A

cirrhosis

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15
Q

what is the annual risk of developing HCC in patients with cirrhosis

A

around 2 %

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16
Q

what is the leading cause of HCC in the absence of cirrhosis

A

NAFLD - approximately 1/4 to 1/3 of NAFLD-related HCC occurs in the absence of cirrhosis

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17
Q

what beverage may be recommended for patients with chronic liver disease

A

Coffee (but with no additives)
At least one cup of coffee consumption is dose-dependently assocated with a significant reduction in HCC risk

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18
Q

what medications have a protective effect against HCC

A
  1. aspirin (43-60% reduction in HCC risk with aspirin use exceeding 5 years)
  2. statins (potential benefit from lipophilic statins but not hydrophilic statins)
  3. metformin (conflicting data)

https://journals.lww.com/hep/fulltext/2023/12000/aasld_practice_guidance_on_prevention,_diagnosis,.27.aspx

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19
Q

should statins be avoided in patients with chronic liver disease

A

No

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20
Q

does HCC surveillance have any benefit in patients with Child-Turcotte-Pugh score C

A

No, unless they are a transplant candidate

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21
Q

what is the difference between MASH and NAFLD

A

MASH is a more severe form of NAFLD. It includes all the features of NAFLD but with additional inflammation and liver cell injury.

MASH has a higher risk of progressing to advanced liver diseases compared to simple NAFLD.

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22
Q

What stage of fibrosis is considered cirrhosis

A

Stage 4

Stages of Liver Fibrosis
F0: No fibrosis.
F1: Mild fibrosis with portal expansion.
F2: Moderate fibrosis with more extensive portal expansion and some bridging fibrosis.
F3: Severe fibrosis with bridging fibrosis but no cirrhosis.
F4: Cirrhosis. This stage is characterized by extensive fibrosis with the formation of regenerative nodules and significant disruption of liver architecture

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23
Q

what surveillance test(s) do the AASLD recommend

A

combo of US and AFP
https://journals.lww.com/hep/fulltext/2023/12000/aasld_practice_guidance_on_prevention,_diagnosis,.27.aspx

24
Q

GALAD panel sensitivity range for early HCC detection

A

60-80% sensitivity
82% specificity

Berhane S, Toyoda H, Tada T, Kumada T, Kagebayashi C, Satomura S, et al. Role of the GALAD and BALAD-2 Serologic Models in Diagnosis of Hepatocellular Carcinoma and Prediction of Survival in Patients. Clin Gastroenterol Hepatol. 2016;14:875–886 e876.

Marrero JA, Marsh TL, Parikh ND, Roberts LR, Schwartz ME, Nguyen MH, et al. GALAD score improves early detection of HCC prior to the diagnosis of HCC: A phase 3 biomarker validation study. Abstract #138. Hepatology. 2021;74:92A.

25
Q

GALAD panel composition

A

gender, age, AFP-L3, AFP, DCP

26
Q

how often should HCC surveillance be performed

A

every 6 months
*this recommendation was initially based on HCC tumor doubling time

27
Q

AFP 20 ng/mL sensitivity and specificity

A

sensitivity around 60%
specificity around 90%

28
Q

AASLD next step if screening US for HCC shows a subcentimeter lesion

A

Repeat US and AFP in 3-6 months

29
Q

AASLD next step if screening US for HCC shows a 1 cm or greater lesion

A

further imaging with multiphasic CT or MRI

30
Q

percentage of HCC that can have normal AFP levels

A

over 40%

Arif D, Mettler T, Adeyi OA. Mimics of hepatocellular carcinoma:
a review and an approach to avoiding histopathological
diagnostic missteps. Hum Pathol. 2021;112:116–27

31
Q

other tumors that may have elevated AFP levels

A

intrahepatic cholangiocarcinoma, gastric cancer, and germ cell tumors

32
Q

is the diagnosis of HCC based on elevated AFP alone valid

A

no - need imaging or biopsy if imaging non-characteristic

33
Q

who does LI-RADS not apply to

A

patients without cirrhosis or at-risk chronic HBV infection

34
Q

when is a CT chest recommended for patients with HCC

A

when tumor is 2 cm or greater in size to assess for lung mets
*all patients beyond stage 0 of the BCLC criteria

35
Q

when is staging with CT pelvis and Technetium-99m Bone scan recommended for HCC

A
  1. patients with AFP greater than 1000 ng/mL
  2. macrovascular invasion
  3. multifocal bilobar disease
36
Q

factors to consider for surgical resection of HCC

A
  1. tumor number
  2. anatomic location
  3. presence of vascular invasion
  4. anticipated FLR
  5. liver function
  6. presence of clinically significant portal hypertension
37
Q

FLR needed with cirrhosis vs. without

A

40% with cirrhosis
30% without cirrhosis

38
Q

how is clinically significant portal hypertension defined

A

HVPG greater than 10

39
Q

what are surrogates for CSPH when not using HVPG

A

presence of ascites and varices, and platelet count <100k

40
Q

risk of HCC recurrence following surgical resection

A

50-70% at 5 years

40
Q

high risk features for HCC resection patients

A
  1. tumor size greater than 5 cm
  2. more than 3 tumors
  3. micro/macrovascular invasion
  4. poor tumor differentiation
40
Q

what is the recommended treatment for localized HCC in the absence of underlying cirrhosis

A

surgical resection

40
Q

when should surgical resection be considered in patients with cirrhosis

A

when there is
1. limited tumor burden
2. well-compensated cirrhosis
3. no CSPH
4. adequate FLR

41
Q

what type of therapy is recommended for post-resection HCC patient with high risk of recurrence

A

adjuvant treatment with atezo and Bev (IMbrave 050)

42
Q

HCC recurrence rate after transplantation vs. resection

A

transplantation: 10%
resection: 50-60%

AASLD paper: file:///C:/Users/George/Downloads/aasld_practice_guidance_on_prevention,_diagnosis,.27%20(2).pdf

43
Q

what is the criteria for HCC transplant known as

A

the Milan criteria

44
Q

what is used to rank liver transplant candidates

A

MELD-Na

45
Q

what type of immune checkpoint inhibitors are there for HCC treatment

A
  1. anti-PD-1
  2. anti-PD-L1
46
Q

what are the Anti-PD-1 immune checkpoint inhibitors

A

nivolumab (Opdivo) and pembrolizumab (Keytruda)

47
Q

what are the anti-PD-L1 immune checkpoint inhibitors

A

Atezolizumab (Tecentriq)
Avelumab (Bavencio)
Durvalumab (Imfinzi)

48
Q

What risk to immune check point inhibitors carry in cases for potential liver transplant

A

Immune checkpoint inhibitors (ICIs) may increase risk of
rejection and graft loss,

49
Q

If a patient was on an immune checkpoint inhibitor for liver transplant bridging, how long should they be off of them prior to transplant

A

If patients receive ICIs prior to LT, we recommend
discontinuation of these agents at least 3 months prior
to LT - per AASLD guidelines

50
Q

recurrence rate of HCC post liver transplant

A

Even with adherence to the Milan criteria, HCC recurs
post-LT in 10%–15%

51
Q

the two most common sites for post liver transplant HCC recurrence

A

the lung (40%) and the liver (33%)

52
Q

HCC ablation has a similar survival for tumors of what size

A

2 cm or less

53
Q

what did the IMbrave 050 study results demonstrate

A

IMbrave 050 phase III RCT
demonstrated superior recurrence-free survival
using atezolizumab plus bevacizumab in the adjuvant
setting for HCC patients at high-risk of recurrence after
surgical resection or local ablation.

High-risk features for patients undergoing ablation in this trial included tumor size >2 cm but ≤5 cm and multifocal HCC.

IR Oncology (5 decks)

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