kinds of liver cancers diagnosis and treatements

Liver: An EnigmaLiver: An Enigma

ByByDr. S K Mathur MS, FACSDr. S K Mathur MS, FACSSr. Consultant GI SurgeonSr. Consultant GI Surgeon

HPB Surgery & Liver Transplantation, HPB Surgery & Liver Transplantation, Wockhardt hospitals, Mumbai

Past President : Indian Chapter of International HPB Association Indian Association

LiverLiver

Unique Unique

Functionally ComplexFunctionally Complex

EnigmaticEnigmatic

ResectableResectable

TransplantableTransplantable

Liver: An EnigmaLiver: An Enigma

•Liver is the largest organ in the body: wt 1.2-1.5 Kg•Liver is the most complex organ in the body

•From ancient times liver is considered the “organ of fate”

•Egyptians considered the liver to be the “seat of the life force”

Liver: a Unique organ

• Anatomy:

- Dual blood supply

* Portal Vein

* Hepatic artery

HA supplies 35% of blood flow

Segmental anatomy

Prediction of Hepatic Insufficiency

Hepatic VolumetryNormal Liver :

Segments Volume

5 + 8 30 %

6 + 7 35 %

1 + 4 20 %

2 + 3 15 %

65 % of Right Liver65 % of Right Liver

35 % of Left Liver35 % of Left Liver

(Stone et al Am J Surg 1969)(Stone et al Am J Surg 1969)

Liver : UniquenessIt has large functional reserve

For survival:For survival: 35% of functional liver 35% of functional liver

Liver : UniquenessCapacity for Regeneration

In 6 weeks liver regenerates to 90% of its original volume

In Greek mythology, Prometheus (Ancient Greek:"forethought")[1] is a Titan known for his wily intelligence, who stole fire from Zeus and gave it to mortals for their use.[2] Zeus then punished him for his crime by having him bound to a rock while an eagle ate his liver every day only to have it grow back to be eaten again the next day.

http://en.wikipedia.org/wiki/File:Koeln_wrm_1044.jpg

Liver: an enigmato Clinicians

Liver Tumors

Parenchymal Liver Diseases

Cirrhosis

Liver cell failure Death

Liver Tumors• Benign

- FNH

- Adenoma

- Hemangioma

• Cystic

- Congenital

- Hydatid

- Cyst adenoma

• Infective: - Tuberculoma

MalignantPrimary: - HCC - hepatoblastoma - cystadenocarcinoma - Neuroendocrine - Lymphoma

Metastasis: - Colo-rectal - Neuroendocrine

Liver Cancer (Hepatocellular Carcinoma)

Hepatocellular Carcinoma

• 80 % of all liver tumors

• Male : Female = 3 : 1

• HCC Underlying chronic liver

disease (Cirrhosis : 80-90%)

Normal Liver

Tumour doubling time :

median 4-5 months (<5cm)


• Prevalence:

* Annual incidence of 1 Million new cases

* Geographical distribution parallels

The incidence of HBV infection• High Incidence areas:

South-east Asia: 10-20 per 100,000 population• Intermediate Incidence:

Japan, Middle-east, Mediterranean• Low Incidence: India, South Africa• Lowest Incidence: 1-3 per 100,000 population

Australia, USA, Europe


• Prevalence:

* Annual incidence of 1 Million new cases

Digestive cancers at TMH 1994-95

Site 1994 1995

All GI 2277 2347

Esophagus 902 921

Large bowel 617 666

Stomach 359 341

Gall bladder 161 167

Pancreas 1 12 134

Liver 88 88

Others 28 30


Chronic Viral Hepatitis:

• Hepatitis B virus: 80 % of all HCC have HBs Ag +ve Relative risk : 200 fold greater than non-infected - Duration of Chronic HBs Ag carriers and risk of HCC: Strong correlation Childhood infection : risk of HCC 40% Adults: risk of HCC 10% • Hepatitis C virus: - In Japan, Spain, and Italy 80% of all HCC are +ve for Anti HCV

Etiology Etiology ::


Cirrhosis of liver: due to-• Chronic Alcohol abuse• Non-alcoholic Fatty Liver Disease (NASH)• Other Causes: - Budd - Chiari syndrome - 1 antitrypsin deficiency - Haemochromatosis• Aflotoxins : Toxins of Aspergillus flavus & parasiticus (B1,B2 & G1,G2) Food products: e.g. peanuts & grains


• Synthetic heaptocarcinogens :

- Azo dyes, aromatic amines,

- pesticides, chlorinated hydrocarbons• Miscellaneous :

- Oral contraceptives

- Anabolic steroids

- Radiation

- Thorotrast



Hepatocellular CarcinomaClinical Presentations

• Delayed: - Absence of Specific Symptoms - Non-palpable liver - Large Functional hepatic reserve• Anorexia & Weight loss• Fever• Pain in abdomen: Rupture & bleed: Localised: D/D Acute MI • G.I. bleed: - Variceal due to acute PV Thrombosis - Hemobilia• Obstructive Jaundice


Diagnosis :Tumour Markers: -

- AFP > 400 ng/ml

- DCP (des - y - carboxy prothrombin)

- CEA

• USG

• CT : Contrast enhanced CT - 70 %

Biphasic Helical CT (PV : tumour v/s bland thrombus)

a) Arterial phase - Hyperdense

b) Portal venous phase - Hypo or isodense

c) Delayed peripheral enhancement – capsulation

• CT angiography

• Lipiodol CT

• MRI - Dynamic bolus gadolinium injection

(diagnostic accuracy > CT)

• Hepatic Angiography

• PET Scan

For small HCC (3mm)For small HCC (3mm)

Imaging Modalities:


Treatment Options:

Surgical

Non-Surgical


Non surgical therapies

• Systemic chemotherapy

• Intra-arterial chemotherapy (TAC)

• Trans arterial embolisation (TAE)

• Trans Arterial chemo-embolisation (TACE)

• Trans arterial Radio-embolisation: I131or Y90

Local Ablation Therapies:

• Intra-tumoural ethanol injection

• Radio frequency ablation

• Cryoablation

Non surgical therapiesNon surgical therapies

Surgical TherapiesSurgical Therapies

Liver ResectionLiver Resection

Liver TransplantationLiver Transplantation

SURGERY- ANTERIOR TRANSHEPATIC RESECTION

Weight 2 .5Kg

Management of HCC

• Surgical resection : best therapy

Survival - 3yrs : 68 – 76%

- 5yrs : 51 – 68%

*Resection rates : 9 – 37% (Ref: SCNA 2004, Ann Surg 2002)

• Liver Transplantation :

Cures underlying liver disease

Survival : 5yrs : 50 – 60% (71 – 78%)

Selection criteria : T1 & T2 lesions

Problem : Donor shortage ( Ref: Am J Surg 2002, Arch Surg 2001, Hepatology 2001)

Management of HCC

• Recurrence of Liver tumor after resection:

Incidence: 30%

What are the treatment options?

Repeat Surgery

( Re-resection of Liver)

Or

Non- surgical therapies

Story of a patient with recurrent liver cancer

Agony to Smile

HISTORY

• 58 year old male• October 2006: Diagnosed to have a tumor in his liver on

USG • CT Scan Confirmed the tumor to be single and localised

in his right half of the liver• CT guided biopsy reported as:

well differentiated Hepatocellular Carcinoma

• Tumor Marker : AFP was normal


October 2006:

• Evaluated at a Cancer hospital

• No Co –morbid diseases

• No spread of tumor out side liver

• He underwent Liver resection for his tumor

• Was asymptomatic 2 ½ years post surgery.

• In April 2009 : during a follow up USG at the previous hospital

- detected to have recurrence of his tumor at the cut margin of the liver

- CT Scan confirmed the recurrence of the tumor : Three tumors close to each other

•Deemed not suitable for re surgery i.e. re-Deemed not suitable for re surgery i.e. re-resection of the liver tumor: resection of the liver tumor:

•Resurgery on liver is considered hazardous due Resurgery on liver is considered hazardous due to adhesions to surrounding organs:to adhesions to surrounding organs: e.g. Diaphragm, colon, duodenume.g. Diaphragm, colon, duodenum

•One tumor nodule was close to & extending One tumor nodule was close to & extending behind the IVCbehind the IVC

IVC

Tumors Tumor

Liver

Advised Palliative Treatment:Advised Palliative Treatment: Underwent two cycles of TACE in April Underwent two cycles of TACE in April and June 2009and June 2009

One tumor nodule which was flush with One tumor nodule which was flush with the IVC could not be embolisedthe IVC could not be embolised

Management of HCC

• Recurrence of Liver tumor after resection:

Incidence: 30%

What are the treatment options?

Repeat Surgery

( Re-resection of Liver)

Or

Non- surgical therapies

Selection Criteria for Repeat Hepatectomy in Patients With Recurrent Hepatocellular Carcinoma Masami Minagawa, MD,*

Masatoshi Makuuchi, MD,* Tadatoshi Takayama, MD,† and Norihiro Kokudo, MD* Ann Surg. 2003

• The most widely used treatment of intrahepatic recurrence is transarterial chemoembolization (TACE).

• The 5-year survival rate has ranged from 0% to 27% in patients with postresectional recurrence, even with repeated TACE.

• It is questionable whether this procedure actually enhances survival in such cases.

Selection Criteria for Repeat Hepatectomy in Patients With Recurrent Hepatocellular Carcinoma Masami

Minagawa, MD,* Masatoshi Makuuchi, MD,* Tadatoshi Takayama, MD,† and

Norihiro Kokudo, MD* Ann Surg. 2003

• Repeat resection for recurrent HCC has been reported to be a highly effective treatment in selected patients.

• The 5-year survival rate after repeat resection has been reported to be from 37% to 70%.

Repeat resection for recurrent HCC in selected patients:-

hepatic resection is the treatment of choice for patients

• who have previously undergone resection of a single HCC at the primary resection

• in whom recurrence developed after a disease-free interval of 1 year or more

• the recurrent tumor had no portal invasion.


• August 2009:Came for 2nd opinion:

Evaluation at Wockhardt Hospitals: Patient is well built and nourished No comorbid illness No spread of tumor out side the liver Remaining liver normal Treatment Offered: Re-resection of the liver

CT ScanCT Scan

Sectorectomy

Right hepatectomy

Story of a patient with Story of a patient with recurrent liver cancerrecurrent liver cancer

Video

•Postoperative course was uneventfulPostoperative course was uneventful

•Out of ICU on Day 2Out of ICU on Day 2

•Discharged from the hospital on Day 6Discharged from the hospital on Day 6

•Histopathology reported as necrotic tumor at the Histopathology reported as necrotic tumor at the previous resection siteprevious resection site

•Viable tumor adjacent to the stump of the RHV and Viable tumor adjacent to the stump of the RHV and IVCIVC

Dealing with Cancer and Terrorism

Prevention

Early detection

and effective damage control


• Prevention

– HBV infection: Vaccination programme– HCV: Safe Blood bank Practices– Alcoholism : Awareness & Control– Obesity Control: Life style Modification– Aflotoxins : awareness

ConclusionsConclusions

• Screening X

• Surveillance Yes

Diagnosed cases of Cirrhosis

• Programme:

- AFP every 3 month

- USG every 3-6 months

• Any suspicious new lesion : CECT

Early DetectionScreening or Survilliance

• Resection is the best treatment

Assessment for resection by a Liver Surgeon

• Unresectable: due to Anatomical factors

- Chemo-embolisation +/- RFA: to shrink

- Portal vein Embolisation:

Induce hypertrophy of Normal liver

Re-asses for Resection• Unresectable due to Advanced liver disease:

Evaluate for Liver Transplantation

Appropriate Management

Unresectable & Non-Transplant Candidates

- No evidence of Metastasis• Consider Palliation:

- PEI

- RF Ablation

- TACE

- Trans arterial radio-embolisation

• Long-acting Octeriotide: Selected patients

Appropriate Management

kinds of liver cancers diagnosis and treatements

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