HEPATIC TUMORS

HEPATIC HEPATIC TUMORSTUMORS

Dr.Cengiz PataDr.Cengiz Pata

Gastroenterology DepartmentGastroenterology Department

Yeditepe University,IstanbulYeditepe University,Istanbul

clasificationclasification

Primer malign tumorsPrimer malign tumors HEPATOCELLULER CAHEPATOCELLULER CA HEPATOBLASTOMAHEPATOBLASTOMA ANGİOSARCOMAANGİOSARCOMASeconder malign tumorsSeconder malign tumors METASTATİCMETASTATİCBenign tumorsBenign tumors HEPATOCELLULER ADENOMAHEPATOCELLULER ADENOMA CAVERNOUS HEMANGİOMACAVERNOUS HEMANGİOMA HEMANGİOENDOTHELİOMAHEMANGİOENDOTHELİOMA FOCAL NODULER HYPERPLASİAFOCAL NODULER HYPERPLASİA

HEPATOCELLULER HEPATOCELLULER CARCİNOMACARCİNOMA

Clinical PresentationClinical Presentation

Worldwide, over 1 million cases of HCC Worldwide, over 1 million cases of HCC occure every year.occure every year.

The incidence of HCC is higher in areas of The incidence of HCC is higher in areas of the world that have high hepatitis B and C the world that have high hepatitis B and C carrier rates.carrier rates.

HCC typically develops in the setting of HCC typically develops in the setting of chronic liver disease or cirrhosis.chronic liver disease or cirrhosis.

Risk factors for HCCRisk factors for HCC

Hepatitis B carrierHepatitis B carrier Chronic hepatitis C viral infectionChronic hepatitis C viral infection AlfatoxinAlfatoxin Chronic hepatitis ( any cause )Chronic hepatitis ( any cause ) Cirrhosis ( any cause )Cirrhosis ( any cause ) İnactive viral enfectionİnactive viral enfection

Clinical PresentationClinical Presentation Not uncommonly, HCC present without Not uncommonly, HCC present without

symptoms other than those related to the symptoms other than those related to the chronic liver disease or cirrhosis.chronic liver disease or cirrhosis.

HCC should be suspected in cirrhotic HCC should be suspected in cirrhotic patients who present with any of the patients who present with any of the fallowing:fallowing:

1. Deterioration in liver function1. Deterioration in liver function 2. Acute complication ( ascites, variceal 2. Acute complication ( ascites, variceal

bleed, jaundice, encephalopathy)bleed, jaundice, encephalopathy)

SymptomsSymptoms Right upper quadrant painRight upper quadrant pain Right shoulder pain ( suggestive of Right shoulder pain ( suggestive of

diaphragmatic involvement )diaphragmatic involvement ) Acute abdominal pain ( tumor rupture or Acute abdominal pain ( tumor rupture or

hemorrhage )hemorrhage ) FatigueFatigue AnorexiaAnorexia Weight lossWeight loss FeverFever Night sweatsNight sweats

SignsSigns HepatomegalyHepatomegaly Abdominal massAbdominal mass Ascites ( rapid progression suggests Ascites ( rapid progression suggests

Budd-Chiari syndrome )Budd-Chiari syndrome ) Bruit ( heard over the liver, occasional Bruit ( heard over the liver, occasional

finding )finding ) Physical exam finding related to the Physical exam finding related to the

chronic liver disease or cirrhosis ( eg, chronic liver disease or cirrhosis ( eg, jaundice )jaundice )

Laboratory Testing-1Laboratory Testing-1

Liver function test abnormalities consistent with Liver function test abnormalities consistent with cirrhosis are frequently present since most HCC cirrhosis are frequently present since most HCC arise in the setting of cirrhosis:arise in the setting of cirrhosis: ThrombocytopeniaThrombocytopenia HypoalbuminemiaHypoalbuminemia Increased PTIncreased PT Increased BilirubinIncreased Bilirubin Normal or mild increase in transaminase Normal or mild increase in transaminase

levelslevels Normal or increased ALP levelNormal or increased ALP level

Laboratory Testing-2Laboratory Testing-2%75-90 of patients with HCC have an elevated AFP level.%75-90 of patients with HCC have an elevated AFP level. AFP levels may be elaveted other hepatic diseases such as AFP levels may be elaveted other hepatic diseases such as

hepatitis ( acute or chronic ) and cirrhosis.hepatitis ( acute or chronic ) and cirrhosis. Many experts maintain that an AFP level > 500 Many experts maintain that an AFP level > 500 g/L is g/L is

diagnostic for HCC in a patient who is at risk for this type diagnostic for HCC in a patient who is at risk for this type of cancer.of cancer.

In patients who have AFP elevation due to HCC, the In patients who have AFP elevation due to HCC, the degree of elevation is not related to the stage of the tumor, degree of elevation is not related to the stage of the tumor, size of the lesion, or prognosis of the patient.size of the lesion, or prognosis of the patient.

With tumor resection, AFP levels often return to normal.With tumor resection, AFP levels often return to normal. AFP levels are useful in monitoring patients for tumor AFP levels are useful in monitoring patients for tumor

recurrence following tumor resection.recurrence following tumor resection.

UltrasonographyUltrasonography Small tumors are often hypoechotic but with growth, the Small tumors are often hypoechotic but with growth, the

tumor is more likely to be isoechotic or even hyperechotic. tumor is more likely to be isoechotic or even hyperechotic. US findings that are particulary suggestive of the US findings that are particulary suggestive of the diagnosis are ill-defined margins and coarse, irregular diagnosis are ill-defined margins and coarse, irregular internal echoes.internal echoes.

Will identify most HCC but cannot reliably distinguish Will identify most HCC but cannot reliably distinguish these lesions from other hepatic lesions. As a result, other these lesions from other hepatic lesions. As a result, other imaging test modalities are often necessary.imaging test modalities are often necessary.

The detection of a hepatic mass in combination with an The detection of a hepatic mass in combination with an AFP level > 500 mg/L is considered to be diagnostic for AFP level > 500 mg/L is considered to be diagnostic for HCC.HCC.

Percutaneous ultrasound-guiged FNA of a liver mass can Percutaneous ultrasound-guiged FNA of a liver mass can be done to establish the diagnosis but complications be done to establish the diagnosis but complications include hemorrhage and tumor seeding.include hemorrhage and tumor seeding.

CT-Scan CT-Scan ( With intravenous ( With intravenous contrast )contrast )

Can identify tumors < 1 cm.Can identify tumors < 1 cm. CT scan has greater sensivity and spesificity than CT scan has greater sensivity and spesificity than

US, especially for tumors < 1 cm.US, especially for tumors < 1 cm. CT is often done to evaluate an abnormality first CT is often done to evaluate an abnormality first

detectedon US. In some centers, however, it is detectedon US. In some centers, however, it is the initial imaging modality in the patient the initial imaging modality in the patient suspected of having HCC.suspected of having HCC.

Percutaneous CT-guiged FNA of a liver mass can Percutaneous CT-guiged FNA of a liver mass can be done to establish the diagnosis but be done to establish the diagnosis but complications include hemorrhage and tumor complications include hemorrhage and tumor seeding.seeding.

MRIMRI Sensitivity of MRI is similar to that Sensitivity of MRI is similar to that

of helical CT.of helical CT. Nonetheless , CT is preferred over Nonetheless , CT is preferred over

MRI because of cost.MRI because of cost. Consider MRI over CT scan if patient Consider MRI over CT scan if patient

has renal insufficiency, allergy to has renal insufficiency, allergy to contrast dye, or CT results that are contrast dye, or CT results that are equivocal.equivocal.

Paraneoplastic Paraneoplastic manifestationsmanifestations

HypoglycemiaHypoglycemia PolycthemiaPolycthemia HypercalcemiaHypercalcemia Sexual changesSexual changes Arterial hypertensionArterial hypertension DiarrheDiarrhe PorphyriaPorphyria Carcinoid syndromeCarcinoid syndrome OsteoperosisOsteoperosis TyhrotoxicosisTyhrotoxicosis PolymyositisPolymyositis Cutaneos markers: pitriasis rotunda, Cutaneos markers: pitriasis rotunda,

dermatomyositisdermatomyositis

Okuda Staging System for HCCOkuda Staging System for HCC

CriteriaCriteria PositivePositive NegativeNegative

Tumor sizeTumor size >%50>%50 < %50< %50

AscitesAscites Clinically Clinically detectabledetectable

Clinically absentClinically absent

AlbuminAlbumin < 3 mg/dL< 3 mg/dL > 3 mg/dL> 3 mg/dL

BilirubinBilirubin > 3 mg/dL> 3 mg/dL < 3 mg/dL< 3 mg/dL

StagingStaging Stage IStage I No positives from the above tableNo positives from the above table

( median survival 8.3 months )( median survival 8.3 months )

Stage IIStage II One or two positives from the above tableOne or two positives from the above table

( median survival 2 months )( median survival 2 months )

Stage IIIStage III Three or four positives from the above tableThree or four positives from the above table

( median survival 0.7 months )( median survival 0.7 months )

Adverse Prognostic Adverse Prognostic FactorsFactors

Advanced ageAdvanced age Male sexMale sex JaundiceJaundice AnorexiaAnorexia Poor performance statusPoor performance status

treatmenttreatment

SurgicalSurgical

-resection-resection

-transplantation-transplantation NonsurgicalNonsurgical

-cheomtherapy (adriamycine, SORAFENİB)-cheomtherapy (adriamycine, SORAFENİB)

-TACE (lipiodol, gelfoam )-TACE (lipiodol, gelfoam )

-ethonol injection-ethonol injection

-RF, cryosurgery-RF, cryosurgery

Treatment-1Treatment-1 Surgical resection should be considered if the Surgical resection should be considered if the

HCC is resectable and the patient is a candidate HCC is resectable and the patient is a candidate for resection.for resection.

1.1. The likelihood that resction will succesfull depends upon The likelihood that resction will succesfull depends upon the size ( < 5 cm ) and location of the tumor. In addition, the size ( < 5 cm ) and location of the tumor. In addition, success is also dependent upon whether the remaining success is also dependent upon whether the remaining hepatic parenchyma compensate for that which is resectedhepatic parenchyma compensate for that which is resected

2.2. Ideal candidate has a solitary mass that does not invade Ideal candidate has a solitary mass that does not invade the vasculature, good hepatic function, and no portal the vasculature, good hepatic function, and no portal hypertension.hypertension.

3.3. Lobar resection can often be performed in patients with Lobar resection can often be performed in patients with Child’s class A cirrhosis.Child’s class A cirrhosis.

4.4. Because of the high recurrence rate after resection, Because of the high recurrence rate after resection, postoperative adjuvant therapy should be considered. postoperative adjuvant therapy should be considered.

Treatment-2Treatment-2 Orthoptic liver transplantation has had Orthoptic liver transplantation has had

promising results in the treatment of HCC but is promising results in the treatment of HCC but is limited by the long wait that is often needed for limited by the long wait that is often needed for the donor liver.the donor liver.

Percutaneous ethanol injection and Percutaneous ethanol injection and radiofrequency ablation should be considered in radiofrequency ablation should be considered in patients with HCC who cannot withstand patients with HCC who cannot withstand resction because of poor hepatic reserve.resction because of poor hepatic reserve.

Transarterial chemoembolization can be Transarterial chemoembolization can be considered in patients with large, unresectable considered in patients with large, unresectable HCC.HCC.

Systemic chemotherapy and radiotherapy of Systemic chemotherapy and radiotherapy of limited benefit in HCC.limited benefit in HCC.