The day,gone,

1. The day,gone, Never come again

2. HCC Therapy & Prevention

3. Introduction • Hepatocellular carcinoma (HCC) represents more than5% of all cancers in the world, and the estimated number of cancer-related deaths exceeds 500,000 per year. • Two major epidemiological facts characterize this cancer: • It occurs in a previously diseased liver, • The causes of The underlying liver disease differ according to the Geographical distribution. Journal of Hepatology 38 (2003) S136–S149

4. Introduction • Common risk factors for HCC include: HBV, HCV, cirrhosis of any cause, alcoholic liver disease, and inherited metabolic diseases such as hemochromatosis and a1-antitrypsin deficiency. • HCC occurs most commonly in sub-Saharan Africa and parts of the Far East such as China, Taiwan, Korea, Japan, and Vietnam. • HCV infection with advanced fibrosis or cirrhosis is the main cause of HCC in Egypt. Gastroenterol 2006; 12(22): 3575-3580

5. Symptoms • Many people with HCC have no symptoms until the disease becomes advanced. Among the common symptoms of advanced HCC are: • Abdominal pain • Abdominal swelling • Weight loss • Decreased energy • Fevers of unknown source • Shoulder pain • Bone pain

6. Tumor markers • It is very important to detect HCC at its earlier period. • By reasons of convenience, inexpensiveness, and the satisfactory accuracy, serum tumor markers have been used as an effective method for detecting malignant tumors for a long time, and they could be valuable supplementaries to U/S and CT in the diagnosis of HCC. • Using the appropriate single or combination of tumor markers may improve the effectiveness in screening HCC patients.

7. Tumor markers Oncofetal and glycoprotein antigens Enzymes and Isoenzymes Genes Cytokines • AFP mRNA • GGT mRNA • hTERT mRNA • VEGF • IL-8 • TGF-β-1 • TSGF • AFP & AFP-L3 • GPC3 • DCP • GGT II • AFU • AFP, AFP-L3 and DCP are the most useful serum tumor markers for the detection of HCC, and the simultaneous determination of these markers could improve the accuracy, especially in differentiating HCC from nonmalignant hepatopathy.

8. Tumor markers Oncofetal and glycoprotein antigens Enzymes and Isoenzymes Genes Cytokines • AFP mRNA • GGT mRNA • hTERT mRNA • VEGF • IL-8 • TGF-β-1 • TSGF • AFP & AFP-L3 • GPC3 • DCP • GGT II • AFU • Other tumor markers could be used as supplementaries to AFP and DCP in the diagnosis of HCC, but each of them has no satisfactory accuracy in detecting HCC or prefiguring the prognosis when used alone.

9. Imaging • U/S: very difficult to detect lesions less than 2 cm. • New imaging technology, either by CT-scan or last generation MRI: • Allows the studying of tumours with contrast injection at an early arterial phase, as well as at the parenchymatous and portal phase. • HCC is characterized by arterial hypervascularization followed by a rapid wash-out, appearing hypovascular in the portal phase. Other signs are the existence of a capsule or pseudocapsule and the presence of fat or haemorrhage inside the tumour.

10. Biopsy • HCCdiagnosiswas established on the basis of histological or cytological proof. • Limitations to biopsy have been well documented for small and large tumours: • In small early tumours: • False negative results may be as high as 40%. • Some of them are difficult to reach. • In larger tumours: • The risk of complications(3%). • The establishment of a firmdiagnosisof well differentiatedHCCwith a small histological sample can be difficult, and may require additional samples or cytological smears, each of these procedures carrying a risk.

11. Recently Non-invasive criteria for the diagnosis of HCC in cirrhotic patients: • Based on the following: • The incidence of HCC is high in cirrhotic patients; • Any FHL growing in a cirrhotic liver has a high probability of being neoplastic: • Most HCCs are hypervascularized by an arterial route in contrast with the absent or discrete hypervascularization of other lesions.

12. Recently Non-invasive criteria for the diagnosis of HCC in cirrhotic patients: • HCC diagnosis was established by: • The coincidental findings of two imaging techniques showing a nodule of >2 cm with arterial hypervascularization, • Or by a single positive imaging technique associated with AFP of >400 ng/ml. • These criteria are simple, specific and easy to use, even by a non-specialist.

13. Recently Non-invasive criteria for the diagnosis of HCC in cirrhotic patients: • A focal growing lesion in a cirrhotic liver accompanied by a progressively increasing serum AFP (even below 400 ng/ml) or an arterially hypervascularized tumour in a non-cirrhotic liver accompanied by a markedly elevated serum AFP are also fairly specific. • These non-invasive criteria have yet to be validated in a large scale. • In addition, new criteria must also be developed for tumours less than 2 cm in diameter.

14. Treatment • Before any decision is made for treating a patient with HCC, the following questions have to be addressed. • What is the status of the non-tumorous liver? • What is the size and extension of the tumour? • What is the general condition of the patient, their age and their expected life expectancy?

15. Treatment • Curative treatment: • Resection. • Liver transplantation. • Percutaneous ablation: • PEI • PAI • RFA • Microwave ablation • Cryoablation • Laser ablation • Palliative treatment: • Embolisation. • Chemoembolisation. • Arterial or systemic chemotherapy. • Internal radiation. • Proton beam radiation. • Hormonal compounds. • Immunotherapy.

16. Treatment PEI and PAI • Achieves complete responses of 70% in HCC ≤ 3 cm. • It is considered the gold standard treatment.

17. RFA Treatment Principle Equipment Lesion Anaethesia Timing Giudance Follow up Complications

18. RFA Treatment Principle Equipment Lesion Anaethesia Timing Giudance Follow up Complications

19. RFA Treatment Principle Equipment Lesion Anaethesia Timing Giudance Follow up Complications

20. RFA Treatment Principle Equipment Lesion Anaethesia Timing Giudance Follow up Complications

21. RFA Treatment Principle Equipment Lesion Anaethesia Timing Giudance Follow up Complications

22. RFA Treatment Principle Equipment Lesion Anaethesia Timing Giudance Follow up Complications

23. RFA Treatment Principle Equipment Lesion Anaethesia Timing Giudance Follow up Complications