Essam Abdul Wahab Lecturer of Internal Medicine Hepatogastroenterlogy Unit Focal Hepatic Lesions Focusing On Hepatocellular Carcinoma
Dec 30, 2015
Essam Abdul WahabLecturer of Internal Medicine
Hepatogastroenterlogy Unit
Focal Hepatic Lesions
Focusing On Hepatocellular Carcinoma
@ Identify the common focal hepatic lesions.
@ Know the risk factors, Diagnosis, and management of hepatocellular carcinoma.
Home message.
Objectives
Focal hepatic Lesions
Focal Hepatic Lesions
Hemangioma
Focal nodular hyperplasia
Adenoma
Liver cysts
1- Primary liver cancers
Hepatocellular carcinoma
Fibrolamellar carcinoma
Hepatoblastoma
2. Metastases
Benign Malignant
Benign Liver Lesions
Hemangioma
Focal nodular hyperplasia
Adenoma
Cysts
Hemangioma
The commonest liver tumor 5% of autopsies
Usually single small with demarcated capsule.
Usually asymptomatic.US: well demarcated echogenic spot.CT: venous enhancement from periphery to centerMRI: high intensity areaNo need for FNANo need for treatment ??
Focal Nodular Hyperplasia (FNH)Benign nodule formation of normal liver with Central stellate scar.
Common in young and middle age women
No relation with sex hormones.
Asymptomatic, may cause minimal pain.US: Nodule with varying echogenicityCT: Hypervascular mass with central scarMRI: iso or hypo intense FNA: Normal hepatocytes and Kupffer cells with central core.No treatment necessary.Pregnancy and hormones----- OK.
Benign neoplasm ---- normal hepatocytes but no portal tract, central veins, or bile ducts.More common in women.Usually asymptomatic but may have RUQ pain.May presents with rupture, hemorrhage, or malignant transformation (very rare).US: filling defectCT: Diffuse arterial enhancementMRI: hypo or hyper intense lesionFNA : may be neededStop hormones, Observe every 6m If no regression then surgical excision.
Hepatic Adenoma
Liver Cysts
May be single or multiple
May be part of polycystic kidney disease.
Patients often asymptomatic.
No specific management required.
Hydated cyst.
Leader
1928-----2001
Malignant Liver Tumors
Hepatocellular carcinoma (HCC) 90%
Fibro-lamellar carcinoma of the liver
Hepatoblastoma
Intrahepatic cholangiocarcinoma
Secondary liver tumors.
US: HCC Jaundiced
‘Time’ is the best kept secret of the rich..!
Jim Rohn
HCC: Risk FactorsThe most important risk factor is cirrhosis from any cause.
Hepatitis B (integrates in DNA) regress now in Egypt
Hepatitis C(common in our country)
Alcohol
Aflatoxin
Hemochromatosis
Patients for Whom HCC Surveillance Is Recommended
HBV carrier with HCC family history
Cirrhotic HBV carriers
Hepatitis C with cirrhosis
Stage 4 primary biliary cirrhosis
Genetic hemochromatosis and cirrhosis
Alpha-1 antitrypsin deficiency and cirrhosis
Other cirrhosis
80% of patients with HCC have underlying cirrhosis
Bruix J, et al. AASLD HCC guidelines. July 2010. Simonetti RS, et al. Dig Dis Sci. 1991;36:962-972.
Malignant Transformation
Potential Targets
Oxidative stress and inflammation
Viral oncogenes
Carcinogens
Growth factors Telomere shortening
Cancer stem cells
Loss of cell cycle checkpoints
Antiapoptosis Angiogenesis
Normal liver
Liver cirrhosis
Hepatitis C,BEthanolNASH
Epigenetic alterationsGenetic alterations
HCC[2]
Dysplastic nodules[1]
1. Tornillo L, et al. Lab Invest. 2002;82:547-553. 2. Verslype C, et al. AASLD 2007. Abstract 24.
Diagnosis of HCC
Clinical
Examination
AFP
Detection
Radiological
Assessment Biopsy
C/p1- HCC usually have no symptoms other
than those related to their chronic liver
disease.
2- Sudden decompensation as
ascites, encephalopathy,
jaundice, or variceal bleeding.
3- Mild to moderate -upper abdominal pain, weight loss, early satiety, or a
palpable mass in the upper abdomen.
4- Hypercalcemia , hypoglycemia,
erythrocytosis, and watery diarrhea
5- features of metastases
HCC: labs…AFP (Alfa Feto Protein)
HCC tumor marker since 1968.
> 200 ng/ml are highly suggestive of HCC.
Elevation seen in more than 70% of pt.
Serum level increase also in chronic hepatitis and liver cirrhosis.
Sensitivity 60 % and specificity 94 %.
Small HCCs are usually non AFP secreting.
Radiology
HCC can be diagnosed radiologically, without the need for biopsy if the typical imaging features are present.
Requires a contrast-enhanced study:• 1- CEUS
• 2- Dynamic CT.
• 3- Dynamic MRI.
Contract enhanced US (CEUS)
Using microbubble structure, consisting of gas bubbles stabilized by a shell.
The sizes of the bubbles are not small to be lost by lung or large to pass to extracellular like CT and MRI.
CEUS allows visualization of the arterial ,portal phase and late phase that differs from the late phase of extracellular (CT) and (MRI) agents in that it is prolonged more than 5 minutes and may reflect sinusoid pooling and RES or Kupffer cell uptake
Enhanced CT arterial phase
Venous phase Delayed phase
Biopsy Often not necessary. Most focal liver lesions have characteristic radiological findings on CT or MRI.
Recommended in uncertain cases.
Many debates regarding tunneling of tumor cells. .
HCC: Prognosis
Tumor size
Spread
Underlying liver disease
Patient status
HCC Management
Surgical resection
Liver
Transplantation Percutaneous
ablation...
HCC: Liver Transplantation
Best available treatment.
Removes tumor and liver.
Only if single tumor less than 5cm or less than 3 tumors less than 3 cm each.
Recurrence rate is low.
Not widely available.
HCC: Resection
Feasible for small tumors with preserved liver function (no jaundice or portal HTN)
Recurrence rate is high.
HCC: Loco -Regional Ablation
• For non respectable pt. temporary measure only as bridge for liver transplantation.
• For pt. with advanced liver cirrhosis:• Percutaneous Ethanol injection(PEI)• Radiofrequency ablation(RFA)• Tran arterial chemoembolization (TACE)• Microwave Coagulation.
Ethanol InjectionIt is the best known and best studied approach.
It achieves necrosis rate of:
90-100% of the HCC smaller than 2 cm
70% in tumors between 2 and 3 cm
50% HCC between 3 and 5 cm.
Radio Frequency Ablation
Deliver heat around the tip induces a wide region of
tumor necrosis.
The efficacy of RFA in tumors <2 cm is similar to that
of ethanol but requires fewer treatment sessions. The
efficacy in tumors >2 cm is better than with ethanol
.
Follow up The efficacy of percutaneous ablation is assessed
by dynamic CT or MR one month after therapy
The absence of contrast uptake within the tumor
reflects tumor necrosis, while the persistence of
contrast uptake indicates treatment failure
HCC: ChemoembolizationInject chemotherapy selectively in hepatic artery
Then inject an embolic agent……
Only in pts. with early cirrhosis….
No role for systemic chemotherapy
Chemoembolization
Systemic Chemotherapy
• For advance HCC with accepted liver function:
• HCC has been considered to be a relatively chemo and radio-resistant.
• Survival is often determined by degree of hepatic dysfunction.
• Systemic chemotherapy is not well tolerated by most patients.
HCC is an evolving and explosive problem in Egypt.
HCC is tightly related to chronic HCV infection.
Early diagnosis of respectable of loco regional eligible HCC is a major interest.
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