HEPATOCELLULAR
CARCINOMA
Monton
HCC in Thailand
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Most common cancer in Thai male
Incidence 5 x 100,000 / year
Male : female = 3-8:1
Age > 40 yr
HCC in Thailand
• 60-90% associated with cirrhosis
• Risk factor
–
–
–
–
HBV 35-85%
HCV 18.6%
Alcohol ~10%
etc. aflatoxin
Multisteps carcinogenesis
CIRRHOSIS
AFLATOXIN
INITIATION
PHASE
HBV
HBC
ALCOHOL
PROMOTION
PHASE
Cause of death
• Hepatic failure
• GI bleeding
• Cancer death
39-45%
13.8-23.3%
10%
Diagnostic criteria
EASL conference 2000
• Cyto-histological criteria
• Non-invasive criteria(cirrhosis)
1.Radiological criteria : 2 imaging
- focal mass > 2 cm
- 1 imaging show hypervascularization
2.Combined criteria
- 1 imaging mass >2cm,hypervascularization
- AFP > 400 ng/ml
Staging
• No standard staging system
• Most system focus on
1.performance status
2.tumor characteristics
intrahepatic and extrahepatic
3.liver function
• French,CLIP,BCLC,CUPI,TNM
Treatment
• Curative
– Surgery
– Liver transplantation
– Percutaneous : PEI,RFA
• Palliative
– TACE
– Hormone
– Systemic chemotherapy
Surgery
• First choice in non-cirrhotic pt
• 5yr survival ~ 50%
• High recurrent rate : 50% in 3yr
• Suspect undetected micrometastasis
• 4,000-10,000 baht
Liver transplantation
• Cure underlying cirrhosis
• 5yr survival ~ 70%
• Milan criteria
• 1 mass
• 3 mass
, < 5 cm
, < 3 cm
• Less available
• Long term immunosuppression
• 300,000 – 500,000 Baht
Percutaneous
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Alternative in unresectable tumor
No destruction to non-tumor tissue
Can do in cirrhosis
Tumor seeding is problem
PEI : percutaneous ethanol injection
– 2,000 baht
• RFA : radiofrequency ablation
– 40,000 baht
TACE
• Transarterial chemoembolization
• Palliative treatment
• Principle
– Cytotoxic agent(doxorubicin/cis) + lipiodol
– Embolization
• Improvement in 2yr survival
• 10,000 – 30,000 baht
Contraindication of TACE
• Decompensated cirrhosis
particularly bilirubin > 2 mg/dl
• Encephalopathy
• Reverse or absent portal flow
• Tumor burden > 50% of liver
• Renal failure
• Active infection
Systemic therapy
• Hormonal rx
– not improve survival
• Systemic chemotherapy
– not improve survival compared with best
supportive care
Future trends
• Antiangiogenic agent
– Vascular endothelial growth factor inhibitor
• Immunotherapy
– Tumor specific effector T-cell
• Gene therapy
– Intratumoral immunomodulatory cytokine
Problem
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Most patients are unresectable
High recurrent rate after surgery
Cannot detect micrometastasis
Early detection of HCC is appropriate
HCC surveilance
• Focus on cirrhotic patients
• Tumor doubling time ~ 6 mo
• Tools are
1. AFP
2. Ultrasonography
AFP
• Produced from
– Fetal liver cell
– Yolk sac
• Normal range 10-20 ng/ml
• AFP increases in
– exacerbation of chronic viral hepatitis (20-250
ng/ml)
– Germ cell tumor
AFP cut-off
Cut-off
sens
spec
NPV
PPV
20
200
400
60
22.4
17.1
89.4
99.4
99.4
97.7
25.1
Trevisani et al,J Hepatol,2001
USG
• Sensitivity
USG
CT
MRI
79.4
87.6
88.9
Yao et al,J Hepatol,2001
Surviellance & recall strategy
USG/AFP q 6mo
liver nodule
1-2cm
>2cm
FNAB
AFP>400
imaging
no nodule
<1cm
AFP^
AFP-
spiralCT
USG/3mo
no HCC
HCC
surveillance/6mo
Bruix J et al. J Hepatol,2001
Thank you