Hepatocellular carcinoma

Hepatocellular carcinoma is now increasingly common malignancy that is faced now a millions of people around the world.

1. HEPATOCELLULAR CARCINOMA Presented by : Dr . Aleena Bhari Dr.Kawshik Ahmed Intern doctors, Surgery department Enam medical college and hospital

2. Anatomy of liver

3. Surgical anatomy The Couinaud classification system divides liver into 8 independent functional units (segements)

4. Contd.. The segments are numbered 1- 8. The separation of segments is based on its own dual vascular inflow,biliary drainage and lymphatic drainage. In general each segment is wedge shaped with apex directed towards hepatic hilium(porta hepatis) Segment 1 is caudate lobe lies posterior around IVC Segment 1- 5 makeup left hemiliver and remaining right . For liver to remain viable, resection occur along hepatic veins and portal vein in the planes that define boundaries of these segments.

5. INCIDENCE 28/100000 in SEA 10/100000 in SE 5/100000 IN NE Incidence is increasing day by day due to -chronic hepatitis B &C virus infection. -cirrhosis due to any cause. The disease is more common in male(4:1)usually in middle age group(50years).

6. AETIOLOGICAL FACTORS COMMON Viral infection-HEPATITIS B&/C External source-alcohol,aflatoxin. Cirrhosis from any cause. Non alcoholic steatohepatitis(NASH) Wide spread infection with liverflukes-Clonorchis sinensis. UNCOMMON Primary biliary cirrhosis Hemachromatosis alpha 1 Antitrypsin deficiency Wilson disease

7. Pathogenesis The exact pathogenesis is unknown. The disease seems to occur in stages: Chronic liver injury > cell death >regeneration> cellular metabolic dysfunction> release of inflammatory mediators> increase risk of transforming mutation of hepatocytes. Preneoplastic changes –hepatocytes dysplasia can be seen.

8. Clinical presentation Symptoms: Asymptomatic in early stages,discovered only by screening (ultrasound and AFP). Presents with abdominal mass which produces discomfort &dragging sensation on exercise. Weakness,malaise,abdominal or chest pain,vomiting,jaundice,haematemesis. Anorexia,weightloss –incase of metastasis.

9. Contd…. Sign: Jaundice Ascites Hepatomegaly Periumbilical collateral veins Variceal bleeding Easy bruising Hepatic encephalopathy Shock

10. Contd… Local examination: Palpable mass in right upper abdomen which is hard,irregular,tender/nontender. Hepatic bruit

11. SPREAD Tend to spread by invasion into vasculature mostly portal vein. Highly metastasis to lymphnode. Lung and bone metastasis in terminal cases.

12. Diagnosis: Diagnosis of HCC is done by : 1. Clinical presentation 2. Investigation 3. Staging

13. 1.Investigation : Imaging: - Ultrasonography - CT Scan - MRI -Angiography Liver biposy : - percutanous aspiration or core biopsy -

14. Images of investigation

15. Contd.. Tumor markers: - AFP measurement -viral marker Liver radio isotope scans Liver function test: - serum bilirubin - AST - ALT - ALP -Prothrombin time -Serum albumin

16. Contd..

17. MRI Studies Showing the Effects of Hepatocellular Carcinoma at Different Stages of the Disease . El-Serag HB. N Engl J Med 2011;365:1118-1127 A: Very early stage (one lesion 1.7cm), B: early stage (2 lesions 2.4 and 1.2 cm) C: Intermediate stage (multiple lesions, Childs B), D: Advanced (large mass and ascites)

18. 2.Staging: OKUDA staging system Clinical parameters cut off value points Tumor size >50% <50% 1 Ascites Present absent 1 Serum albumin(mg/dl) >3 <3 1 Serum total bilirubin(mg/dl) <3 >3 1

19. Contd.. STAGE 1 =0 STAGE 2=1-2 points STAGE 3=3-4 points

20. TNM STAGING

21. Patient assesment: By CHILD-TURCOTTE-PUGH Score Measurements Score 1 2 3 Encephalopathy None Mild Moderate Ascites None Slight Moderate Bilirubin(mg/dl) 1-2 2-3 >3 Albumin(g/dl) >3.5 2. 8-3.5 < 2. 8 Prothrombin time <4 sec 4-6 sec >6 sec

22. Contd.. STAGE A =5-6 points STAGE B =7-9 points STAGE C =10-15 points

23. Interpretation: Points Class 1 year survival 1 year survival 5-6 A 100% 85% 7-9 B 8 1 % 57 % 10-15 C 45% 35%

24. Screening for HCC Aim: Early asymptomatic curable. Methods: AFP (every 6 month) & Ultrasound Indications: For patient at risk for HCC:- -Cirrhosis -Hepatitis B,C -Alcohol consumption -Genetic hemachromatosis -Autoimmune hepatitis -Non alcoholic steatohepatitis -Primary biliary cirrhosis -Alpha1 antitrypsin deficiency

25. Treatment Surgical approach Non surgical therapy

26. Surgical approach Segmental or local resection Lobectomy or partial hepatectomy Extended lobectomy Liver transplantation

27. Contd.. First 3 for: Liver transplantation for: Single tumor within single segment Child Turcotte Stage A Tumor size <5 cm Multiple tumor size of each <3cm Single tumor size<5cm Multiple tumor sizeof each<3cm No vascular invasion No extrahepatic spread

28. Images of surgical treatment

29. B.Nonsurgical therapy Majority of HCC not be amenable to surgical resection because of :- =Advanced stage of the carcinoma & =Severity of the underlying liver disease

30. Contd.. The options are: Ablative - Ethanol injection -Acetic acid injection -Thermal(cryotherapy,readiotherapy,microwave) Transarterial - Embolization -Chemoembolization Systemic - Chemotherapy -Radiotherapy -Imunotherapy

31. Radiofrequency ablation

32. Transarterial chemo embolization

33. Prognosis after treatment: 5 year survival rate:- 30-40% after liver resection 5year survival rate:- 75% in liver transplantation 2 year survival rate :- 60% in transarterial chemoembolization

34. Conclusion In brief ,preventing and treating viral hepatitis may help to reduce the risk of developing liver cancer.Childhood hepatitis vaccination of hepatitis B may reduce risk of it.Proper nutrition,rest,good habits(avoid alcohol) and safer practises makes a man healthy.