Hepatocellular Carcinoma

Transcription

1 PSH Clinical Guidelines Statement 2017 Hepatocellular Carcinoma Dr. Zia ud Din Associate professor of medicine Lady Reading Hospital Peshawar INTRODUCTION Hepatocellular carcinoma is the primary liver cancer and is major health problem. It is the 3 rd cause of cancer related death and accounts for 7percent of all cancers. 1 The incidence of HCC increases with advancing age and peaks at 70 years age. Males are more affected as compared to females; with male to female ratio estimated to be 2.4 2,3. It has the largest incidence in East Asia and Subsaharan Africa. 4 ETIOLOGICAL AND RISK FACTORS The most common underlying risk elements include chronic hepatitis B and C, alcohol intake and exposure to alfatoxin. 5 Cirrhosis is an important causative factor and maybe caused by chronic viral hepatitis, alcohol, non alcohol fatty liver disease and metabolic diseases like hemochromatosis or alpha1 antitrypsin deficiency. Approximately 1/3 rd of the cirrhotic patient will develop HCC during the lifetime. 6,7 Diabetes mellitus,cigarette smoking, obesity, HIV infectivity and fatty liver diseases have been linked to the development of HCC. 8,9 DIAGNOSIS Diagnosis of HCC is based on non-invasive criteria or pathology. Early HCC diagnosis is possible in 30 to 60 % of cases. 10,11 Non invasive criteria are accurate for the diagnosis of HCC with specificity of 100% and is based on a combination of imaging and laboratory findings. 12,13 Different imaging modalities are nowadays available such as ultrasound scan,4-phasic multidimensional CT scan, dynamic contrast-enhanced MRI. 14 Diagnosis is based on the identification of typical hallmark of HCC i,e, contrast uptake in the arterial phases and washout in the venous late phase PATHOLOGICAL DIAGNOSIS AFP is the most widely tested biomarker in HCC. AFP levels above 400 ng/ ml are considered as diagnostic. 18 Other serological tests of early HCC includes des-gammacarboxy prothrombin [DCP] and tissue marker GPC3. 19 Sensitivity of liver biopsy depends upon location, size and expertise. It has some limitations due to complications such as bleeding and needle tract seeding. 20 STAGGING SYSTEM Main prognostic variables are tumor stage, liver function and performance status. 21 BCLC [Barcelona Clinic Liver Cancer] is recommended for prognostic prediction and

2 treatment allocation. This classification divides HCC into 5 stages: 1. BCLC Stage 0 {Very Early HCC} is defined as the presence of single tumor less than 2cm without vascular invasion in patient with good health status BCLC Stage A [Early HCC} is defined as the presence of tumor greater than 2cm or presence of 3 nodules less than 3cm of diameter in patient with child-pugh A or B BCLC Stage B [Intermediate HCC] multinodular, asymptomatic tumor without an invasive pattern BCLC Stage C [Advanced HCC] symptomatic tumor with macro vascular invasion or extra hepatic spread BCLC Stage D [End-stage HCC] are characterized by presenting with tumors leading to very poor health performance and severe tumor related disability. 26 TREATMENT Treatment is based on the BCLC allocation system: RESECTION is the first line treatment option in patients with solitary tumor and well preserved liver functions, it is also indicated in patient with multifocal tumor [less than 3 nodules less than 3cm]. Tumor recurrence is the major complication of resection. 27,28 LIVER TRANSPLANTATION is considered to the first line treatment for patients with single tumor less than 5cm or less than 3 nodules less than 3cm not suitable for resection. Living donor liver transplantation is an alternative option in patient with a waiting list exceeding 6 to 7 months. 29,30 LOCAL ABLATION with radiofrequency or percutaneous ethanol injection is the standard therapy for patient with BCLC 0 - A tumors not suitable for surgery. 31 CHEMO EMBOLISATION is recommended for patient with BCLC Stage B, multinodular asymptomatic tumor without vascular invasion or extra hepatic spread. it is contraindicated in decompensated liver diseases, macroscopic invasion or extra hepatic spread. 32,33 SYSTEMIC THERAPY: Sorafenib is indicated in patient with well preserved liver function [CHILD- PUGH A CLASS] and with advanced tumors [BCLC C]. 34,35 Patient at BCLC-D needs palliative support, which includes pain management, nutritional and psychological support. PREVENTION Vaccination against hepatitis c is recommended to all newborns and to high-risk groups. In patient with chronic hepatitis, antiviral therapy leading to maintained HBV suppression in chronic hepatitis B and SVR in hepatitis C are recommended, since they have been showed to prevent progression to cirrhosis and hence HCC development. 36

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