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Multidisciplinary approach to HCC

Multidisciplinary approach to HCC. Moderator – Dr Sunil K Mathai Panelists Dr Sudhindran Dr Sreekumar Dr Prakash Zacharia Dr Jose Francis. Case -1. 45 year male who is known case of HBV related Cirrhosis on entacavir is found to have a 4cm lesion in right lobe seument 6.

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Multidisciplinary approach to HCC

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  1. Multidisciplinary approach to HCC Moderator – Dr Sunil K Mathai Panelists Dr Sudhindran Dr Sreekumar Dr Prakash Zacharia Dr Jose Francis

  2. Case -1 • 45 year male who is known case of HBV related Cirrhosis on entacavir is found to have a 4cm lesion in right lobe seument 6.

  3. How would you further evaluate this lesion- Dr PZ

  4. 4 cm lesion in HBV related Cirrhotic liver • Further Imaging • 4Phase MDCT / MRI • Diagnosis - Typical Characters of HCC • Multifocal or not • Vascular involvement • Nodes • Status of Liver & virus • General Condition of patient

  5. Imaging modalities in HCC – Dr SM • CT/MRI in HCC • Kupffer specific imaging

  6. Imaging in HCC • Contrast Enhanced 4 phase MDCT • Contrast MRI • Contrast USG

  7. Would you biopsy the lesion– Dr Jose • Indications for biopsy in suspected HCC

  8. Would you biopsy the lesion? No JF

  9. Why? • If curative therapeutic attempts are planned, including surgery - Biopsy is often contraindicated Stigliano R et al Cancer Treat, Rev.2007; 33:437-447 • Avoid the risk of seeding (2.7%) Perkins JD et al L. Hepatol. 1999;30: 472-478 JF

  10. Why? • Likelihood of HCC is > 90% - If AFP is > 200 ng/ml - Setting of a mass in a cirrhotic liver Torzilli G et al Hepatology1999;30: 889-893 JF

  11. Why? • Diagnosis confidently established - Presence of typical imaging features • Four-phase multidetector CT (the four phases) - Unenhanced, - Arterial, hyperattenuating - Venous, and hypoattenuating (washout) - Delayed • Dynamic contrast-enhanced MRI JF

  12. Algorithm JF

  13. Case continued …. • Investigation were s/o HCC

  14. How will you stage the lesion – Dr PZ Overview of staging systems

  15. Investigations • Liver lesion - assessment • Child Status • Portal Hypertension • Platelet count (<1lakh) with splenomegaly • OGD for varices, If no varices -?HVPG • Evidence of dissemination • Assessment of patient • Other medical conditions • Performance Status

  16. BCLC Staging

  17. How will you assess the functional liver reserve – Dr Jose • Scoring systems ( MELD,CTP ) versus Role of HVPG Role of ICG

  18. Hepatic functional reserve • Related to - Quantity - Quality of liver cells • Assessment of remaining liver prior to hepatectomy JF

  19. Assess functional liver reserve • MELD score • ICG Clearance • CT measurement of liver volume • Others - HVPG JF

  20. MELD and HCC • Increase priority of patients for Tx with HCC - Assigned a higher score based on tumour staging • Risk for ‘dropping out’ from the list because of cancer progression JF

  21. MELD and HCC • T2 lesion - 15% risk, score of 22 • 10% mortality bonus every 3 months - Until they are Tx or - No longer suitable for Tx JF

  22. Role of ICG • Qin-Song Sheng, • Hepatobiliary Pancreat Dis Int，Vol 8，No 1 • February 15，2009 • ICG-R15 (N= 3.5% to 10.6% ) • >14% precludes major liver resection

  23. Role of HVPG • MELD scores has been correlated with manifestations of liver disease such as hepatic venous pressure gradiennts • Ripoll C et al Hepatology 2005;42(4);793-801 • Portal hypertension - Independent factor in post-resection outcome - Patients with Child–Pugh class A cirrhosis and minimal portal hypertension - Platelet count >100,000/mm3 and/or - HVPG <10 mmHg) - Are optimum resection candidates JF

  24. CTMeasurement of the liver volume • The percentage of RLV (PRLV) was calculated using the following formula: • PRLV=RLV/predicted total liver volume ×100% • RLV = Total liver tumor - (tumor volume + peri-tumor volume) • The predicted total liver volume (mL) = 121.75 + 16.49 × body mass (kg) JF

  25. Case continued…. • 4cm HCC. Child A CTP- 6/15 MELD- 8. No PV thrombus.

  26. What treatment would you advise here here – Dr Sudhi • Resection v/s Transplant • Indications for resection • Indications of transplant. • Expanding indications for resection • Expanding indications for transplant • Cytoreductive and salvage surgery

  27. Treatment of HCC • Main issues • Survival • Recurrence

  28. HCC- resection • Mainstay of treatment • No Level I evidence • Compelling data from cohort studies • Ideal candidates • Single nodule • Less than 5 cms • No vascular invasion • Contraindication: • Distant metastasis • Main portal vein thrombus • IVC thrombus • Results • 5 yr survival 35 to 70% • Recurrence: 50 to 80%

  29. Transplantation • Theoretically the “best”: • Widest possible resection margin • Removes remnant liver at risk of cancer • Restores liver function • Advanced tumours • High risk of recurrence • Milan criteria • 5 cm • 3 cm (X3) • UCSF • 6.5 cms • 4.5 cm (X3) Upto 7 Largest tumour plus number equals 7 No vascular invasion AFP

  30. Results of transplantation • 5 year survival 60 to 75% • 5 year recurrence rate 30 to 40% • No trial between resection and Tx • If donor (LDLT or DDLT) available, Tx

  31. Suppose you plan for transplant. Would you advise a LDLT ? Dr PZ • Ethics of LDLT in HCC patients

  32. LDLT advantage • LDLT – No or minimal waiting period

  33. Issues • Hep B • Risk to the donor • Adverse tumor factors • Pressure to Expand the criteria (?)

  34. Would you consider RFA/TACE/TARE here. Dr SM • Indications and clinical outcome of RFA • Indications and clinical outcome of TACE/TARE • RFA versus resection/Transplant • RFA versus TACE/TARE

  35. 4cm HCC,Child A • – RFA or TACE with RFA

  36. Ablative therapy • RFA/PEI • Visiblity on USG or plain CT • If visible, relationship with adjacent viscera and vessels

  37. Ablative therapy indications • Child Pugh A or B • Single </= 3cm or 5cm • Multiple nodules </= 3 in number each </= 3cm

  38. Ablative therapy • PEI and RFA complete response in 80% <3 cm • complete response in 50% 3-5cm • 40-70% 5 yr survival which is little less than resection

  39. TACE • Care for Intermediate stage • Child A or B • Single ≥ 5cm and ≤ 8 cm • Multiple more than 3 • LESIONS WHICH ARE IDEAL FOR ABLATION BUT WITH POOR VISBILTY ON USG /CT

  40. TACE • Contra indications • Portal vein thrombosis • Portal flow reversal • Child C cirrhosis

  41. TACE • Partial response in 15-55% • Significantly delays tumour progression • Llovet etal*-Meta analysis • 2yr survival in treated group 41% vs 27% in control group • Llovet JM, Bruix J. Systematic review of randomized trials for unresectable hepatocellular carcinoma: hemoembolization improves survival. Hepatology 2003;37:429–42

  42. TACE • Doxorubicin.Mitomycin C,cisplatin • Conventional TACE with lipiodol • TACE with DEB(DC Beads)

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