HEPATIC TUMORS

1. HEPATIC TUMORS Dr.Cengiz Pata Gastroenterology Department Yeditepe University,Istanbul

2. clasification Primer malign tumors • HEPATOCELLULER CA • HEPATOBLASTOMA • ANGİOSARCOMA Seconder malign tumors METASTATİC Benign tumors • HEPATOCELLULER ADENOMA • CAVERNOUS HEMANGİOMA • HEMANGİOENDOTHELİOMA • FOCAL NODULER HYPERPLASİA

3. HEPATOCELLULER CARCİNOMAClinical Presentation • Worldwide, over 1 million cases of HCC occure every year. • The incidence of HCC is higher in areas of the world that have high hepatitis B and C carrier rates. • HCC typically develops in the setting of chronic liver disease or cirrhosis.

5. Risk factors for HCC • Hepatitis B carrier • Chronic hepatitis C viral infection • Alfatoxin • Chronic hepatitis ( any cause ) • Cirrhosis ( any cause ) • İnactive viral enfection

6. Clinical Presentation • Not uncommonly, HCC present without symptoms other than those related to the chronic liver disease or cirrhosis. • HCC should be suspected in cirrhotic patients who present with any of the fallowing: 1. Deterioration in liver function 2. Acute complication ( ascites, variceal bleed, jaundice, encephalopathy)

7. Symptoms • Right upper quadrant pain • Right shoulder pain ( suggestive of diaphragmatic involvement ) • Acute abdominal pain ( tumor rupture or hemorrhage ) • Fatigue • Anorexia • Weight loss • Fever • Night sweats

8. Signs • Hepatomegaly • Abdominal mass • Ascites ( rapid progression suggests Budd-Chiari syndrome ) • Bruit ( heard over the liver, occasional finding ) • Physical exam finding related to the chronic liver disease or cirrhosis ( eg, jaundice )

9. Laboratory Testing-1 Liver function test abnormalities consistent with cirrhosis are frequently present since most HCC arise in the setting of cirrhosis: • Thrombocytopenia • Hypoalbuminemia • Increased PT • Increased Bilirubin • Normal or mild increase in transaminase levels • Normal or increased ALP level

10. Laboratory Testing-2 %75-90 of patients with HCC have an elevated AFP level. • AFP levels may be elaveted other hepatic diseases such as hepatitis ( acute or chronic ) and cirrhosis. • Many experts maintain that an AFP level > 500 mg/L is diagnostic for HCC in a patient who is at risk for this type of cancer. • In patients who have AFP elevation due to HCC, the degree of elevation is not related to the stage of the tumor, size of the lesion, or prognosis of the patient. • With tumor resection, AFP levels often return to normal. • AFP levels are useful in monitoring patients for tumor recurrence following tumor resection.

11. Ultrasonography • Small tumors are often hypoechotic but with growth, the tumor is more likely to be isoechotic or even hyperechotic. US findings that are particulary suggestive of the diagnosis are ill-defined margins and coarse, irregular internal echoes. • Will identify most HCC but cannot reliably distinguish these lesions from other hepatic lesions. As a result, other imaging test modalities are often necessary. • The detection of a hepatic mass in combination with an AFP level > 500 mg/L is considered to be diagnostic for HCC. • Percutaneous ultrasound-guiged FNA of a liver mass can be done to establish the diagnosis but complications include hemorrhage and tumor seeding.

12. CT-Scan ( With intravenous contrast ) • Can identify tumors < 1 cm. • CT scan has greater sensivity and spesificity than US, especially for tumors < 1 cm. • CT is often done to evaluate an abnormality first detectedon US. In some centers, however, it is the initial imaging modality in the patient suspected of having HCC. • Percutaneous CT-guiged FNA of a liver mass can be done to establish the diagnosis but complications include hemorrhage and tumor seeding.

13. MRI • Sensitivity of MRI is similar to that of helical CT. • Nonetheless , CT is preferred over MRI because of cost. • Consider MRI over CT scan if patient has renal insufficiency, allergy to contrast dye, or CT results that are equivocal.

14. Paraneoplastic manifestations • Hypoglycemia • Polycthemia • Hypercalcemia • Sexual changes • Arterial hypertension • Diarrhe • Porphyria • Carcinoid syndrome • Osteoperosis • Tyhrotoxicosis • Polymyositis • Cutaneos markers: pitriasis rotunda, dermatomyositis

15. Okuda Staging System for HCC

16. Staging • Stage I No positives from the above table ( median survival 8.3 months ) • Stage II One or two positives from the above table ( median survival 2 months ) • Stage III Three or four positives from the above table ( median survival 0.7 months )

17. Adverse Prognostic Factors • Advanced age • Male sex • Jaundice • Anorexia • Poor performance status

18. treatment • Surgical -resection -transplantation • Nonsurgical -cheomtherapy (adriamycine, SORAFENİB) -TACE (lipiodol, gelfoam ) -ethonolinjection -RF, cryosurgery

19. Treatment-1 • Surgical resection should be considered if the HCC is resectable and the patient is a candidate for resection. 1. The likelihood that resction will succesfull depends upon the size ( < 5 cm ) and location of the tumor. In addition, success is also dependent upon whether the remaining hepatic parenchyma compensate for that which is resected 2. Ideal candidate has a solitary mass that does not invade the vasculature, good hepatic function, and no portal hypertension. 3. Lobar resection can often be performed in patients with Child’s class A cirrhosis. 4. Because of the high recurrence rate after resection, postoperative adjuvant therapy should be considered.

20. Treatment-2 • Orthoptic liver transplantation has had promising results in the treatment of HCC but is limited by the long wait that is often needed for the donor liver. • Percutaneous ethanol injection and radiofrequency ablation should be considered in patients with HCC who cannot withstand resction because of poor hepatic reserve. • Transarterial chemoembolization can be considered in patients with large, unresectable HCC. • Systemic chemotherapy and radiotherapy of limited benefit in HCC.