3. liver tumors (Malignant) General Surgery=.pptx

Hepatocellular carcinoma is the most common form of liver cancer. It’s an aggressive (fast-growing) cancer most common in people with advanced liver disease, like cirrhosis of the liver. Increasingly, people diagnosed with HCC have a liver condition that sometimes leads to cirrhosis called metabolic dysfunction-associated steatotic liver disease (MASLD).

In the beginning, hepatocellular carcinoma grows slowly. Surgery to remove the tumor or a liver transplant can treat HCC in its early stages. But most people don’t learn they have it until it’s advanced and spreading more quickly. Eventually, it can lead to liver failure. At this point, HCC is challenging for providers to treat.

Given how serious it is, you should receive regular checks for signs of HCC if you have cirrhosis or MASLD.

1. HCC The most common malignancy originating in the liver, 80% of primary liver cancers. Age > 55 years Men are more likely than women to develop HCC (4:1) 80 % of cases of HCC usually occurs on top of a cirrhotic liver.

2. The types of cirrhosis most commonly associated with HCC: Chronic hepatitis C. Chronic hepatitis B. Hemochromatosis . Alpha-1-antitrypsin deficiency . Alcoholic cirrhosis (alcohol potentiates the carcinogenic risk in viral cirrhosis).

3. Historically , the diagnosis of HCC was almost made when the disease was advanced, when the patients were symptomatic with liver function impairment, at this stage no treatment had any chance of being effective also morbidity associated with the treatment (chemotherapy) was high.

4. Today - Early diagnosis (good liver function and no cancer related symtoms ) - I mprovement of the radiological modalities - Several active treatment available Better survival

5. Serial AFP measurements and abdominal U/S studies are the most commonly used screening tools. - AFP levels every 3 months. - U/S every 6 months .

6. Clinical Presentation Early detection: screening Rapid deterioration of patient with liver cirrhosis: Jaundice, encephalopathy, hematemesis, ascites Abdominal pain, Weight loss, Abd mass. Complications: Rupture and hemoperitoneum

7. Polycythemia. Hypoglycemia. Hypercalcemia. Fever. Paraneoplastic syndrome

8. Diagnosis of HCC Routine liver function tests do not detect the presence of HCC, they can only detect the underlying liver disease. AFP. Normal 0-10 ng/ml More than 200 is suggestive

9. Diagnosis of HCC U/S. Triphasic C.T . MRI with contrast (Gadolinium)

10. Why is FNAC of hepatic masses controversial inoperable primary cancers. Another controversy about the use of FNAC in HCC is the risk of needle-tract seedling and tumor spread into the circulation. Also falacies occur by false –ve result of liver biopsy especially if from a small lesion less than 2 cm.

11. Diagnosis of HCC CT chest PET CT Laparoscopy + US

12. Treatment of HCC Curative : * R0 1- Hepatic resection (segmental and non segmental, major and limited resection) 2- Liver transplantation Palliative : ( inoperable ) = Symptomatic 1- Local ablation (RFA) 2- Trans-Arterial Chemoembolization (TACE) 3- Local Radiotherapy and others…

13. Hepatic Resection Is the treatment of choice of HCC in patients that can tolerate resection Patients have to be carefully selected to diminish the risk of postoperative liver failure and death: Child A No extrahepatic spread No vascular invasion Confined to one lobe

14. Liver transplantation Child C Under the Milan criteria , eligibility for  liver transplantation  is based on the following  single tumor with a diameter of ≤5 cm, or up to 3 tumors each with a diameter of ≤3 cm no extra-hepatic metastases no major vessel involvement

15. Radiofrequency Ablation (RFA) Heat production by needle to induce region of tumour necrosis . Indication : tumor less than 4-5cm. Techniques: Percutaneus or open surgery or laparoscopic , all are under U/S guidance.

16. Transcatheter Arterial Embolization (TACE) Transcatheter injection of chemotherapeutic agent (+ gelfoam ). Used in patients with unresectable HCC for palliation. ► Contraindication : Portal vein thrombosis. Severe cirrhosis (Child C). Bilirubin > 5 mg/dl.

17. Percutaneous Ethanol Injection (PEI) Under guide of U/S Ethanol (5-10 ml) injection 2-3 times a week. Palliative

18. Local Radiotherapy A new promising technique where internal irradiation is delivered through microspheres SYSTEMIC INTERNAL RADIATION THERAPY (SIRT).

19. Systemic Chemotherapy Is a complete failure with no promising results .

20. Hepatic Secondaries Most common Malignant liver tumor . The primary sites include: 1- Portal vein (the commonest ) : colon, rectum, stomach 2- Hepatic artery: lung, kidney 3- Lymphatics: breast 4- Direct: GB

21. Clinical presentation Presentation of the 1ry tumor wt loss, fatigue, anorexia Rt upper abd pain Hepatomegaly Ascites jaundice

22. Diagnosis 1- Labs Anemia Inc bilirubin, AP 2- Rad US, CT, MRI

23. Treatment of hepatic metastases Once livet mets has occurred, the tumor is considered inoperable Palliative systemic chemotherapy

24. Surgical treatment of hepatic metastases from colorectal cancer Surgery has been shown to be safe and potentially curative in the treatment of colorectal metastases to the liver. Indications: هام No extrahepatic disease Completely resectable 1ry tumor Solitary or multiple < 4 The current 5-year survival after a margin-negative hepatic resection is 40%

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