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1. HEPATOCELLULAR
CARCINOMA

3. EMBRYOLOGY

4. GROSS ANATOMY

5. GROSS ANATOMY

6. RELATIONALANATOMY
• Lie on Superior and Anterior
of right kidney
• Anterior : Greater Vessel
• Portal triad enters medially
• Left lobe is the window to
see Pancreas
• Liver is superior and anterior
of Pancreas

7. SIZE AND SHAPE
• Right : Left Lobe # 6 : 1
• Weight : 1200 – 1600 gram
• Length : 15 – 17 cm

8. GROSS ANATOMY : ROLE 4 : 4 : 3
•4 Lobes
•4 Fosssa
•3 Landmarks

9. 4 LOBES
• Left lobe
• Right lobe
• Caudate lobe
• Quadrate lobe

10. 4 Fossaes
• Left Sagittal Fossa: holds/runs the
falciform ligament, Seperates Rt and
Lt Lobes,
• Gallbladder Fossa: Shallow and
oblong; located under the Rt Lobe,
• IVC Fossa: Seperates from the porta
and by the caudate lobe, Holds IVC
• Portal Fossa: Short Deep fissure
extending transversely across under
surface of the left Lobe, Transverse
portal,Hepatic Artery, Hepatic Artery
Nerves and Lymphatic and Bile Duct.

11. 3 Landmarks
• Left Sagittal Fossa/Falciform form Ligament
• Gallbladder Fossa
• Middle Hepatic Vein

12. PORTAL TRIAD
• Hepatic Atery
• Main Portal Vein
• Bile Duct

17. • Fifth most common cancer
• Third cause of cancer related death
• 2012 : # 782 000 case worldwide.
• 83% in less developed regions
• Eastern Asia : 15/100 000
• Vaccination againt HBV  Decrease HCC in high prevalent country.
• Major HBV prevalent ; Age < 60
EPIDEMILOGY

18. EPIDEMILOGY

22. RISK FACTORS
• HBV , HCV, HBV/HCV co-infection
• Alcohol : Higher risks were found even for the lowest dose of alcohol (25 g/day)
• Non-alcohol fatty liver disease (NAFLD)
• Budd – Chiari Syndrome
• HCC in other liver diseases : Other notable causes of cirrhosis can increase the risk of the
development of HCC.
• Alfatoxin
• Tobaco
• Host genetic
• Coffee and tea : coffe - a significant 40% reduced risk, and tea - nonsignificant 23% reduced
risk

23. PATHOGENESIS AND PATHOPHYSIOLOGY

24. PATHOGENESIS AND PATHOPHYSIOLOGY

25. PATHOGENESIS AND PATHOPHYSIOLOGY

27. SURVEILLANCE TEST

28. SURVEILLANCE TEST

30. SURVEILLANCE TEST
The AASLD recommends
surveillance using US, with or
without AFP, every 6 months
HCC on US :
+Hypoechoic lesion.
+Vascularity on doppler

31. • The AASLD recommened not perfoming surveillance of pateints with Child – Pug C
cirrhosis unless they on the transplant waititng list.
• AFP is not recommended to use as surveillance test
• AFP + US  Increase specific and sensitive test
• Other biomarker :
+ AFP – L3%
+ DCP : Des gama carboxyl prothrombin - also called protein induced by vitamin K
absence/antagonist-II, a variant of prothrombin that is also specifically produced at
high levels by a proportion of HCCs
• CT and MRI are not recommended as the primary modality for the surveillance of
HCC in patients with cirrhosis. However, in select patients with a
high likelihood of having an inadequate US or if US is attempted but inadequate, Ct or
MRI may be utilized.
SURVEILLANCE TEST

34. SYMPTOMS
• Asymptoms in early stage
• Right upper pain/ Tenderness
• Weakness
• Malaise
• Vomiting
• Jaundice
• Anorexia, weight lost (>10% in 6 months)
CLINICAL PRESENTATION

35. CLINICAL PRESENTATION
SIGNS
• Jaundice
• Ascites
• Right upper quarter mass
• Catput medusa
• Paraneoplatic syndrome
• HCC Rupture : Serve abdominal pain, hypotesion, shock,…

36. IMAGING BASED DIAGNOSIS
LI – RADS : LIVER IMAGING
REPORTING AND DATA SYSTEM
A classification system for liver lesions which is used
in patients with liver cirrhosis and chronic HBV without
cirrhosis

37. • US LI – RADS
+ Surverlliance HCC
+ Cirrhotic and other high-risk patients
+ Using un-enhancement US
• CT/MRI Diagnostic LI – RADS
+ Dx and staging HCC
+ Cirrhotic and other high-risk patients, HCC patient in liver transplantation list
+ CT, MRI with extracellular agents (ECA), or MRI with hepatobiliary agents (HBA)
• CT/ MRI Tx Response LI – RADS
+ Assessing response of HCC to locoregional treatment
+ Cirrhotic and other high-risk patients, including liver transplant candidates with HCC
+ CT, MRI with extracellular agents (ECA), or MRI with hepatobiliary agents (HBA)
LI – RADS
• CEUS LI – RADS
+ Dx HCC
+ Cirrhotic and other high-risk patients
+ Using contrast enhancement US

38. LI – RADS
5 major feature :
(1) Aterial phase hyperenhancement
(APHE) : APHE is non-rim arterial
hyperenhancement, greater
enhancement liver. Rim-
enhancement is not a feature of
HCC.
(2) Non-peripheral washout :
Decrease in attenuation or intensity
from earlier to later phase
(3) Capsule : Smooth, uniform border
surrounding all or most of an
observation
(4) Size :
(5) Threshold growth : increase in size
of 50% or more within 6 months
time during follow-up imaging

39. LI – RADS

40. LI – RADS

41. LI - RADS

42. • Step 1 – Apply CT/MRI LI – RADS diagnostic algorithm
• Step 2 – Optional : apply ancillary features (AFs)
• Step 3 – Apply Tiebreaking Rules if Needed
• Step 4 – Final Check
LI – RADS

43. LI - RADS

44. LI - RADS

46. LI - RADS

47. LI - RADSLI - RADS

48. LI - RADS

49. AFP using since 1970s,AFP > 500 ng/mL
• Alpha-fetoprotein (AFP) is not recommended as a
confirmatory test in small HCC (B1).
• The cut-off value of AFP should be set at 200 ng/mL
for surveillance programs when used in combination
with US (B2).
• The cut-off value of AFP can be set at lower value in a
population with hepatitis virus suppression or eradication (B2)
TUMOR MARKERS

50. • Des-gamma-carboxyprothrombin (DCP)
+ Promthombin induce VitKabsence-II (PIVKA-II)
+ Increase in HCC patients
+ Cut – off : 40 mAU/ml
+ > AFP in early stage
• Lens culinaris agglutinin-reactive fraction of AFP (AFP-L3)
+ Differentiate an increase in AFP due to HCC from that in patients with benign liver disease
+ Cut – off : 15%
+ AFP < 10 ng/ml  Undetectable AFP – L3
• Glypican – 3 (GPC3)
+ GPC3 messenger RNA levels are increased in HCC
• Other makers : Golgi protein 73 (GP73), osteopontin, circulating cell free DNA and microRNAs
TUMOR MARKERS

51. BIOPSY

52. DIAGNOTIC

53. ABCDE of Child – Turcotte – Pugh
[A] – Albumin
[B] – Bilirubin
[C] – Coagulation (PT – INR)
[D] – Distension (Ascites)
[E] – Encephalopathy
STAGING

54. ECOG Performance Status
STAGING

55. HCC Okuda Staging
STAGING

60. Aims of diagnostic
•Verification of diagnosis
•Extent of disease
•Function of Liver

61. TREATMENT OPTIONS
•Surgical Therapy
•Ablative Therapy
•Transarterial Therapy
•Systemic Therapy
Tx Tumor
Tx Risk Factor
•HBV
•HCV
•Alcohol
•Others

63. Future Liver Remmant (FLR)

64. Indocyanine green (ICG) clearance
ICG clearance was measured as previously described15. In brief, patients
received 0.25 mg/kg ICG intravenously on the day before the liver
resection. The plasma disappearance rate (PDR) and the ICG retention rate
(R15) were measured by pulse spectrometry with a LiMON device (Pulsion
Medical Systems, Munich, Germany). The surgical strategy was not
changed upon the results from the ICG clearance testing.

65. Makuuchi’s Criteria

66. Measuring the portal preasure
• PH equated to
HVPG
(hepatic venous
preasure gradient)
• HVPG = 3-5
mmHg (normal)
• Cirrhosis : HVPG
rise

69. b. R hepatectomy
c. 3D CT FLR : 33%
d. Post-sur : 36%

70. Liver resection
Aim of surgery :
+ Complete resection, least 1 cm margin
+ Maximum preservation of normal hepatic parenchyma
Periopertive mortatily rate < 7%
5 yrs overall survival rate : 30 – 50%

71. Type of hepatic resection
Non-anatomic resection
Anatomic resection
+ Segmentectomy
+ Lobectomy (R and L)
+ Trisgenmentectomy

73. a. Completed R hepatectomy
b. Extended R hepatectomy
c. Completed L hepatectomy
d. Extended L hepatectomy

75. Indication

76. Patient selection

79. 4 Main Connections
IVC
Portal Vein
Hepatic Atery
Bile Duct

82. Indication : non-surgery HCC
TYPE :
• Radiofrequency ablation (RFA)
• Microwave ablation
• Chemical ablation

83. Radiofrequency ablation (RFA)
Advantages:
+Well tolerated OPD procedure
+ Best suited to small tumors (3-5 cm)
deep within hepatic parenchyma, away from
hilum.
+ Repeated easily especially
percutaneous approach
+Less invasive then resection
Disadvantages :
+ Local recurrence rate : 5 – 20 %
+ Tumor seeding via needle tract
+ Bile duct injury

86. Chemical Ablation
• Use : Ethanol or Acetic acid
• Mechanism : Destroy tumor by
dehydration, protein degenation,
coagulation necrosis & vascular
thrombosis
• Advantage : Inexpensive ;minimally
invasive ; RFA not suitable area;
• Disadvantage : 15% recurrence

88. Transarterial Chemoembolisation (TACE)

90. TACE

94. CASE REPORT
Patient : X Age : 57ys Sex : Male
Admitted hospital : Mass in the liver
CASE HISTORY :
The patient had been well until approximately two years before admission, when a
diagnosis of chronic active hepatitis associated with hepatitis B virus (HBV) infection
was made at another hospital. Lamivudine was started one year before admission; the
results of liver-function tests returned to normal after the treatment was initiated, and the
viral load fell.
A surveillance ultrasonograpic examination of the abdominal area performed five
months before admission revealed a mass, 3 cm in diameter, in the right lobe of the liver.
Four months before admission, computed tomographic (CT) scanning and magnetic
resonance imaging (MRI) of the abdominal area documented a mass, 4 cm in diameter,
in the dome of the right lobe of the liver. Multiple cysts were also present.

95. Two months before admission, a percutaneous fine-needle aspiration biopsy
of the liver was performed at another hospital; pathological examination of a
specimen revealed a poorly differentiated carcinoma, thought to be hepatocellular
carcinoma, cholangiocarcinoma, or metastatic carcinoma.
Six weeks before admission, the patient was referred to the gastrointestinal
cancer center at this hospital. He had lost 1.4 kg in the preceding five months but
felt well. His medications were loratadine and lamivudine. He had undergone a
cholecystectomy nine years earlier. He had a history of 10 pack-years of smoking
but had stopped two years earlier; he rarely drank alcohol and did not abuse
intravenous drugs
He was a native of China and had immigrated to the United States fifteen
years earlier. He was married with two children, who were well. His father was
alive and well in his eighties, his mother had died in her seventies from congestive
heart failure, and two of his five siblings were known to have hepatitis B infection.
CASE REPORT

96. Physical examinations :
• He was slender man without jaundice
• Vital sign : normal
• Perfomrmance status : 0 (Scale 0  5)
• Physical examination revealed no abnormalities
CASE REPORT

97. INVESTIGATION
• CBC : Normal
• Glucose, Albumin, Globulin and Bilirubin, Electrocytes : Normal range
• ALT : 135 U/L ; AST : 78 U/L (Normal : 40 U/L)
• CEA : 1.6 ng/mL
• AFP : 2.6 ng/mL
CASE REPORT
CHILD – PUG A
PS : 0
Okuda Stage I

98. • CT finding :
A mass 4.7 cm x 4.5 cm within the right lobe of the
liver and multiple hepatic cysts.
There was no evidence of metastatic disease.
No gross venous invasion or evidence of cirrhosis
• MRI scanning of the liver showed :
Simple cysts and an arterially enhancing, encapsulated
lesion, 4.7 cm by 4.5 cm, straddling the right and left
lobes of the liver.
CASE REPORT
LI – RADS ?

100. Pathology

101. DEFINITIVE DIAGNOSIS
• Hepatocellular Carcinoma Stage A followed BCLC
2018

103. + Tumor resection
IV, V, VIII
+ Tx HBV infection
+ Supportive care
Following - up:
+ AFP : 3 – 6 month
+ US : 6 month
TREATMENT

105. REFERENCES
• https://slideplayer.com/slide/13189034/
• Diagnosis, Staging, and Management of Hepatocellular Carcinoma: 2018 Practice
Guidance by the American Association for the Study of Liver Diseases
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6047212/
• Case 23-2005: A 57-Year-Old Man with a Mass in the Liver (NEJM)
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3700789/
• https://www.intechopen.com/books/cancer-treatment-conventional-and-innovative-
approaches/the-role-of-surgery-in-the-treatment-of-hepatocellular-carcinoma
• Barcelona guideline for HCC 2018
• LI-RADS: A Case-based Review of the New Categorization of Liver Findings in Patients
with End-Stage Liver Disease
• JHEP report 2019 - Comparison of the current international guidelines on the management
of HCC