Case presentation on hepatocellular carcinoma

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1. NEMMCSH Case presentation on HCC Presenter : Dr Mulusew A. (R1) Moderator: Dr Fitsum D.(Asst prof. of internal medicine & consultant internist) 1/30/2024 HCC 1

2. Outline case Brief overview on HCC HCC Surveillance Portal vein thrombosis in CLD HCC diagnosis Antiviral treatment HBV associated HCC Reference 1/30/2024 HCC 2

3. History Identification Name: B/L Age: 45 Years Sex: Male MRN: 882236 Occupation: Farmer Address: Gibe woreda, Hadiya zone, Ethiopia Source of history: Patient, his chart Marital status: married Admitted: 21/05/16 EC 1/30/2024 HCC 3

4. Chief complaint : worsening of abdominal swelling of 1weak duration HPI : A 45yrs old male presented with worsening of painful abdominal swelling of 1weak duration which initially started 2moths back and was non painful. He has history of unquantified but significant weight loss, appetite loss, LGIF, easy fatiguability and malaise of 7months duration. He has also history of intermittent black tarry stool of 1weak duration and dark urine and decreased sexual desire of 2months duration. 1/30/2024 HCC 4

5. Otherwise No hx of bloody vomiting or no hx of sleep pattern changes. No hx lower extremity swelling or body weakness No hx of yellowish discoloration of eye or skin No hx of orthopnea or PND No hx tattooing, blood letting, blood transfusion, herbal medication use or similar illness in the family 1/30/2024 HCC 5

6. Cont… No hx of river water contact No hx of multiple sexual partner No hx of sharing sharp materials with others No hx of bone pain No hx of alcohol intake or smocking No hx of DM, HTN or Cardiac illness 1/30/2024 HCC 6

7. Physical examination General appearance = Acute sick looking on chronic bases BP = 108/66 mmHg from left brachial artery on sitting position PR = 92 bpm regularly regular and full in volume from radial artery RR = 23 breaths per minute Temperature = 36.9 o c SPO2 = 96% on room air MUAC = 23 cm 1/30/2024 HCC 7

8. HEENT Pink conjunctiva Moderately icteric sclera Dry buccal mucosa No dental caries No septal defect Uvula located centrally No ear discharge 1/30/2024 HCC 8

9. Lymphoglandular system No significant LAP No parotid gland enlargement No palpable anterior neck mass No gynecomastia No testicular atrophy 1/30/2024 HCC 9

10. Respiratory system Inspection No flaring of ala nasae No subcostal retraction No chest deformity No audible stridor or wheezing palpation Central trachea No tenderness No palpable mass Symmetric chest expansion Comparable tactile fremitus 1/30/2024 HCC 10

11. Cont… percussion Resonance percussion note all over the anterior and posterior bilateral lung field Auscultation There is a vesicular breath sound all over the right and left anterior and posterior whole lunge field 1/30/2024 HCC 11

12. Cardio vascular systems Arterial examination All palpable arteries are carotid, radial, brachial, femoral, posterior tibialis, popliteal, dorsalis pedis, are full in volume, regular in rhythm Vinous examination JVP is 2cm above angle of Louis in about 30 degree inclination 1/30/2024 HCC 12

13. Precordial Examination Inspection No precordial bulge Quiet precordium Apical impulse is not visible Palpation PMI is at 5 th intercostal space medial to left mid clavicular line There is no parasternal or apical heave or thrill Auscultation S1 and S2 well heard No murmur or gallop 1/30/2024 HCC 13

14. Abdominal examination Inspection Grossly distended abdomen which moves with respiration Flanks are full Distended paraumbilical veins with everted umbilicus Hernia sites are free Palpation Superficial Mild epigastric and RUQ tenderness No superficial mass Deep Tender on palpation No ballotable mass 1/30/2024 HCC 14

15. Cont… Percussion fluid thrill is positive Auscultation Normoactive bowel sound No bruit over abdominal aorta, renal artery, ileac artery and femoral artery PR = dark and sticky stool on examining finger 1/30/2024 HCC 15

16. Genitourinary system No supra pubic tenderness No costovertebral angel tenderness 1/30/2024 HCC 16

17. Musculoskeletal systems / Integumentary system No deformity Thenar and hypothenar atrophy Comparable temperature No leg edema Palmar erythema bilaterally Scattered hypopigmentation Decreased axillary and pubic hair distribution No clubbing 1/30/2024 HCC 17

18. Neurologic Examination Mental status Conscious and oriented to time, person & place, GCS = 15/15 Mini mental status = 30 Cranial nerve examination CN 1 : He can smell in both nostrils CN 2 : Intact visual field, acuity, identify color CN 2, 3 : Pupil : Mid sized and reactive bilaterally CN 3 ,4, 6 = can move his eye field in all direction 1/30/2024 HCC 18

19. CN 5 : sense light touch and pain over the face CN 7 : face is symmetrical, close her eye, intact nasolabial fold CN 8 : hear finger rubbing bilaterally CN 9, 10 : centrally located uvula, can swallow CN 11 : sternocleidomastoid and trapezius muscle contract CN 12 : the tongue protrude in mid line and no atrophy 1/30/2024 HCC 19

20. Motor Examination Comparable muscle bulk No spontaneous or induced fasciculation Tone power 1/30/2024 HCC 20 Flapping tremor is negative

21. Reflex Superficial Abdominal reflex present both upper and lower quadrant Plantar reflex down going bilaterally Deep tendon reflex 1/30/2024 HCC 21

22. Sensory examination Primary sensation examination Intact sensation for light touch , pin prick over the bilateral right and left extremities and trunk Recognize different movement of the toe with eye closed Cortical sensation Intact graphesthesia, two point discrimination, stereognosis 1/30/2024 HCC 22

23. Meningeal signs No neck stiffness Kerning sign negative Brudzinski's sign negative Scores MELD score = 15 Child Pugh class = C BCLC class = D Milan criteria = not fulfilled 1/30/2024 HCC 23

24. Investigations CBC LFT S/creatinine V/markers 1/30/2024 HCC 24 DATE 18/5/16 18/5/16 18/5/16 18/5/16 WBC 5700 ALT= 57.56u/l Scr= 0.878mg/dl HBVsAg +ve Gran % 68.3% AST= 170.6u/l HCV ab _ve lymph 24.7% ALP= 19.39u/l HGB 11.8 MCV 90 MCHC 31.8 RBS 123mg/dl PLT 157,000

25. Cont… 21/5/16 21/5/16 21/5/16 Ascites albumin 2.1 g/dl T bilirubin 10.72 Na + 134 Serum albumin 3.4 g/dl Indirect bilirubin 1.99 Ca ++ 13.4 INR 0.67 Direct bilirubin 8.7 Cl - 93.7 PT 8.3 Mg ++ 2.8 APTT 25.3 K + 4.6 Ascitic LDH 370 U/L RBS 110mg/dl Ascitic fluid analysis No cell Ascitic fluid cytology pending 1/30/2024 HCC 25

26. Abdominal CT report There is an 4*5.7 cm ill defined lesion seen at the left lobe of the liver involving segment 4 which is hypodense on precontrast and shows enhancement on arterial phase with progressive washout on subsequent phases. The portal vein is dilated and there is a filling defect seen in the main portal vein and its branches which shows similar enhancement pattern as the mass lesion. The back ground liver has smooth contour. Conclusion : left lobe ill-defined lesion with arterial phase enhancement and washout with portal vein tumor thrombus. Ddx HCC 1/30/2024 HCC 26

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28. Assessment Decompensated CLD ( Ascites, ? variceal hemorrhage) 2 nd to HCC 2 nd Chronic HBV infection Rule out SBP Portal vein tumor thrombus Mild anemia 2 nd to Anemia of Chronic Disease 1/30/2024 HCC 28

29. HEPATOCELLULAR CARCINOMA EPIDEMIOLOGY Fifth-most common cancer in the world and the third cause of cancer-related mortality and represents 90% of primary liver cancers Highest incidence rates in Asia and sub-Saharan Africa due to the high prevalence of HBV infection, with 20–35 cases per 100,000 inhabitants. 1/30/2024 HCC 29

30. Cont…. Southern Europe and North America have intermediate incidence rates (10 cases per 100,000) Northern and Western Europe have low incidence rates of <5 cases per 100,000 inhabitants. US, liver cancer is ranked number one in terms of increased mortality during the past two decades, with an incidence of 35,000 cases per year. 1/30/2024 HCC 30

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32. Ethiopia 1/30/2024 HCC 32

33. Aetiology and risk factors Approximately 90% of HCCs are associated with a known underlying aetiology most frequently Chronic viral hepatitis (B and C) Alcohol intake Aflatoxin exposure Cirrhosis is an important risk factor for HCC = 1/3 develop HCC 1/30/2024 HCC 33

34. Surveillance The aim of surveillance is to obtain a reduction in disease related mortality. Achieved through early detection that enhances the applicability and cost-effectiveness of curative therapies. Recommended for patients at high risk for HCC on the basis of cost-effectiveness analyses. 1/30/2024 HCC 34

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36. Overall value of hepatocellular carcinoma (HCC) surveillance is determined by balance of benefits and harms 1/30/2024 HCC 36

37. Diagnosis Imaging-based diagnosis Noninvasive imaging criteria / radiological hallmarks APHE - arterial phase hyperenhancement delayed phase washout 1/30/2024 HCC 37

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40. PATHOLOGIC DIAGNOSIS Pathologic diagnosis is required in two scenarios: In patients without cirrhosis In patients without HBV infection If imaging is not typical by CT and MRI 1/30/2024 HCC 40

41. Staging Systems and Treatment Allocation Aimed at stratifying patients according to prognostic factors and outcome and allocating the best available therapies according to evidence. 1/30/2024 HCC 41

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43. Milan criteria Single tumor with diameter of ≤5 cm or up to 3 tumors each with a diameter of ≤3 cm with No extra hepatic involvement No major vessel involvement Patients fulfilling MC has 4year survival rate of 75% 1/30/2024 HCC 43

44. MELD SCORE 1/30/2024 HCC 44

45. Barcelona Clinic Liver Cancer (BCLC) classification 1/30/2024 HCC 45

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47. PORTAL THROMBOSIS IN PATIENTS WITH AND WITHOUT CIRRHOSIS Related to Virchow’s triad Thrombophilia or increased propensity to thrombosis is the most common cause of PVT in patients without cirrhosis The prevalence of PVT in patients with cirrhosis 1% compensated cirrhosis 20% among patients listed for liver transplantation 1/30/2024 HCC 47

48. Clinical features In patients without cirrhosis acute thrombosis can involve variable extents of the portal vein and presents with Acute abdominal pain Fever Abdominal distention from ascites as well as nausea and splenomegaly 1/30/2024 HCC 48

49. Fate of PVT May resolve with complete recanalization especially in patients with cirrhosis Evolve into a chronic thrombus, with development of Periportal collaterals (portal cavernoma), PH Portosystemic collaterals including esophagogastric varices 1/30/2024 HCC 49

50. Diagnosis Imaging of the liver and its vasculature is needed to confirm the diagnosis of PVT. Doppler ultrasound demonstrate hyperechoic material within the vessel lumen dilatation of the portal vein diminished portal venous flow CT 1/30/2024 HCC 50

51. Approach to management of portal vein thrombosis 1/30/2024 HCC 51

52. Tumor thrombus Tumor extension into a vessel Its presence changes stage, prognosis and treatment Caused by a wide variety of malignancies RCC ACC HCC causes PVTT and HVTT Wilms tumor 1/30/2024 HCC 52

53. Diagnosis IMAGING CT = presence of enhancement MRI = diffusion restriction Angiography = streak and thread appearance FDG-PET = increased activity 1/30/2024 HCC 53

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55. Treatment Sorafenib = 2-3 month survival Surgical resection = east vs western countries Thermal ablation rarely considered SIRT = Selective internal radioembolization TACE = relative contraindication LT = absolute contraindication 1/30/2024 HCC 55

56. Bland vs Tumor thrombus 1/30/2024 HCC 56

57. Antiviral treatment of HBV associated HCC 1/30/2024 HCC 57

58. Patient management Maintenance fluid Ceftriaxone 1gram iv BID Therapeutic tap 500ml stat Followed with neurosign chart RBS QID Advised on disease condition and EGD 1/30/2024 HCC 58

59. Missed opportunities not vaccinated Not screened for HBV infection Not screened for HCC early 1/30/2024 HCC 59

60. Reference Harrison's Principles of Internal Medicine, Twenty First Edition Am J Gastroenterol; published online January 3, 2020 Sleisenger and Fordtran’s gastrointestinal and liver disease 11 th edition AASLD Practice Guidance on prevention, diagnosis, and treatment of hepatocellular carcinoma 1, may 2023 Uptodate 2023 Journal of Hepatocellular Carcinoma 2021:8 1253–1267 1/30/2024 HCC 60

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