Staging & Current treatment of HCC

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1 Staging & Current treatment of HCC Dr.: Adel El Badrawy Badrawy; ; M.D.

2 Staging & Current ttt of HCC Early stage HCC is typically silent. HCC is often advanced at first manifestation. The selective ttt depends on : : The presence of comorbidity. tumor size. tumor location. tumor morphology. the presence of metastatic disease.

3 Team of HCC management 1 Hepatologists. 2 Surgeon. 3 Interventional & diagnostic radiologists. 4 Pathologists. 5 Oncologists. 6 Radiation oncologists.

4 TTT of HCC 1 Surgery. 2 Minimally invasive percutaneous technique. 3 Catheter based ttt.

5 Complete surgical resection followed by the transplantation offers the best long term survival.. All other therapies are palliative. Systemic administration of biologic and chemotherapeutic agents is minimally successful in slowing the growth of HCC and typically is used to control symptoms in patients with overwhelming disease.

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7 The role radiology in the surgical resection: 1. Proper staging. 2. CT & MR angiography can help identify atypical vascular anatomy. 3. By giving special consideration to the couinaud segmentation of the hepatic anatomy, radiologists can provide information that allows limited resection and maximum preservation of functional hepatocytes. 4. Intra operative US to define tumor margins. 5. Percutaneous ablation and trans arterial arterial procedures can potentially stabilize disease in transplantation candidates waiting for donor livers.

8 6. Many transplantation candidates with advanced cirrhosis may benefit from TIPS during the wait for an organ. 7. Partial hepatectomy can be complemented with percutaneous ablation to treat residual or recurrent disease in hepatic remnants. 8. The P.V that perfuse a diseased liver lobe may be selectively embolized prior to resection, to promote liver remnant hypertrophy.? in advanced cirrhosis. 9. Image guided guided procedures may be used to manage any complicated after partial resection or complication.

9 Percutaneous techniques: I Thermal ablation Freezing > cryoablation. Heating >R.F..> Microwave...> Laser ablation. II Chemical ablation.>ethanol. III Intralesional viscum.

10 Catheter based ttt: I Chemoembolization. II Selective Internal radiation therapy.

11 Inclusion criteria for RF ablation: Single tumor < 5m in maximum diameter. Multiple tumors (up to 3?4) with each 3 cm in maximum diameter or smaller. Must be surrounded by 1 cm of normal liver. Absence of P.V. thrombosis. Absence of extra hepatic metastases. Child Pugh A or B. Prothrombin time ratio > 50%. Platelet count > 70,000.

12 Ethanol Injection Mechanism of Action 1. Within neoplastic cells, ethanol cause dehydration of the cytoplasm & subsequent coagulation necrosis, followed by fibrous reaction. 2. Within neoplastic vessels, ethanol induces necrosis of endothelial cells & platelet aggregation, thus causing thrombosis & tissue ischemia. 3. HCC is most responsive tumor.

13 Patient selection : 1. Ethanol ablation is generally performed in cirrhotic patients with HCC. 2. Not effective in metastases. 3. Candidates for ethanol ablation must have tumors those volume is less than 30 % of the total volume of the liver. 4. Contraindications include : Extra hepatic disease Thrombosis of P.V. Prothrombin less than 40 %. Platelet count of less than 40,000/mm3.

14 Technique : : According to size, it is either as an outpatient multi session or as an inpatient one shot technique under general anesthesia. HCC< 5 cm...> outpatient basis. HCC >5 cm treated with the one shot inpatient technique. Ethanol is injected percutaneously under U.S guidance. For outpatient procedure, ml of ethanol is injected/session, 2 times/week total of 4 to 12 sessions. In an inpatient one shot procedure, 62 ml of ethanol is delivered in 13 injections over a mean time of 30 min. The patient has a mean hospital length of stay of 3,8 days. CT is performed to evaluate the success of ttt.

15 Patient outcome : For HCC < 5 cm complete ablation rate is about 70 72%. 72%. For cm encapsulated HCC.. The rate is about 60%. Major complications : 1,7% after mlutisession & 4,6% after one shot injection. 1. Peritoneal hemorrhage. 2. Hemobilia. 3. Liver abscess. Mortality rate : zero after multisession & 0,7% after one shot injection.

16 Chemo immobilization : : Normal liver tissue receives 75% of its blood supply from P.V & 25% from hepatic artery. Hepatic malignancy receive 95% of their blood supply from the hepatic artery. Embolization of the hepatic artery selectively induces ischemic necrosis in tumour,, while the normal liver tissue survives off the portal blood supply. Arterial delivery increase the drug concentration in liver tumors 10 to 100 fold compared with systemic infusion.

17 Patient selection: Chemo embolization embolization is used in primary & metastatic malignant hepatic tumor. HCC tumors designed for catheter based treatment tend to be large, infiltrative, and/or multifocal. Contraindications: 1. absence of hepatopetal portal flow. 2. Encephalopathy. 3. Biliary obstruction; bilirubin levels> 2 mg/d1, lactate dehydrogenase levels >100 U/L; and tumor burden > 50% of the liver. 4. Cardiac or renal insufficiency. 5. Severe thrombocytopenia or leukopenia. 6. Uncorrectable coagulopathy. 7. Atypical arterial anatomy that increase the risk of injury to adjacent gastro intestinal organs non target embolization.

18 Material: Many different pharmaceutical agents and embolization protocols have been used in TACE for the management of unresectable HCC. One commonly used formula contains a mixture of 100 mg cisplatin,, 59mg doxorubicin, and 10 mg mitomycin C in a 1: 1 emulsion with a stable iodinated lipid contrast agent, such as ethiodol which helps to achieve concentration of the drugs in the tumor vasculature. After selective catheterization, this mixture is infused directly into the arterial blood supply to the tumor. It remains unclear to what extent arterial embolization should be included in the transarterial management of HCC.

19 Selective internal radiation therapy (SIRT): Usually involves the delivery of a radioactive material into the arterial blood supply of a tumor after directed catheterization with fluoroscopic guidance. Several isotopes have been investigated in the management of HCC, including: iodine 131. rhenium 188. yttrium 90 (90y)..commonest used in united states in radiolabeled monoclonal antibodies.

20 The propensity for HCC to shunt blood from the arterial to venous system must be taken into consideration with regard to both TACE and SIRT, but the issue is of greatest conern for patients being considered for SIRT. To avoid possible lethal radiation related related injury to the lungs, patients who are to receive 90y must first undergo testing with a direct hepatic arterial infusion of tchnetium 99m (99m Tc) macroaggregated albumin, immediately followed by thoracic and abdominal perfusion scintigraphy.

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