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Ung thư tế bào gan - HCC

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Chẩn đoán và chiến lược quản lý ung thư gan
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Ung thư tế bào gan - HCC

  1. 1. HEPATOCELLULAR CARCINOMA
  2. 2. EMBRYOLOGY
  3. 3. GROSS ANATOMY
  4. 4. GROSS ANATOMY
  5. 5. 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
  6. 6. SIZE AND SHAPE • Right : Left Lobe # 6 : 1 • Weight : 1200 – 1600 gram • Length : 15 – 17 cm
  7. 7. GROSS ANATOMY : ROLE 4 : 4 : 3 •4 Lobes •4 Fosssa •3 Landmarks
  8. 8. 4 LOBES • Left lobe • Right lobe • Caudate lobe • Quadrate lobe
  9. 9. 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.
  10. 10. 3 Landmarks • Left Sagittal Fossa/Falciform form Ligament • Gallbladder Fossa • Middle Hepatic Vein
  11. 11. PORTAL TRIAD • Hepatic Atery • Main Portal Vein • Bile Duct
  12. 12. • 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
  13. 13. EPIDEMILOGY
  14. 14. 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
  15. 15. PATHOGENESIS AND PATHOPHYSIOLOGY
  16. 16. PATHOGENESIS AND PATHOPHYSIOLOGY
  17. 17. PATHOGENESIS AND PATHOPHYSIOLOGY
  18. 18. SURVEILLANCE TEST
  19. 19. SURVEILLANCE TEST
  20. 20. SURVEILLANCE TEST The AASLD recommends surveillance using US, with or without AFP, every 6 months HCC on US : +Hypoechoic lesion. +Vascularity on doppler
  21. 21. • 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
  22. 22. SYMPTOMS • Asymptoms in early stage • Right upper pain/ Tenderness • Weakness • Malaise • Vomiting • Jaundice • Anorexia, weight lost (>10% in 6 months) CLINICAL PRESENTATION
  23. 23. CLINICAL PRESENTATION SIGNS • Jaundice • Ascites • Right upper quarter mass • Catput medusa • Paraneoplatic syndrome • HCC Rupture : Serve abdominal pain, hypotesion, shock,…
  24. 24. 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
  25. 25. • 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
  26. 26. 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
  27. 27. LI – RADS
  28. 28. LI – RADS
  29. 29. LI - RADS
  30. 30. • 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
  31. 31. LI - RADS
  32. 32. LI - RADS
  33. 33. LI - RADS
  34. 34. LI - RADSLI - RADS
  35. 35. LI - RADS
  36. 36. 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
  37. 37. • 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
  38. 38. BIOPSY
  39. 39. DIAGNOTIC
  40. 40. ABCDE of Child – Turcotte – Pugh [A] – Albumin [B] – Bilirubin [C] – Coagulation (PT – INR) [D] – Distension (Ascites) [E] – Encephalopathy STAGING
  41. 41. ECOG Performance Status STAGING
  42. 42. HCC Okuda Staging STAGING
  43. 43. Aims of diagnostic •Verification of diagnosis •Extent of disease •Function of Liver
  44. 44. TREATMENT OPTIONS •Surgical Therapy •Ablative Therapy •Transarterial Therapy •Systemic Therapy Tx Tumor Tx Risk Factor •HBV •HCV •Alcohol •Others
  45. 45. Future Liver Remmant (FLR)
  46. 46. 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.
  47. 47. Makuuchi’s Criteria
  48. 48. Measuring the portal preasure • PH equated to HVPG (hepatic venous preasure gradient) • HVPG = 3-5 mmHg (normal) • Cirrhosis : HVPG rise
  49. 49. b. R hepatectomy c. 3D CT FLR : 33% d. Post-sur : 36%
  50. 50. 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%
  51. 51. Type of hepatic resection Non-anatomic resection Anatomic resection + Segmentectomy + Lobectomy (R and L) + Trisgenmentectomy
  52. 52. a. Completed R hepatectomy b. Extended R hepatectomy c. Completed L hepatectomy d. Extended L hepatectomy
  53. 53. Indication
  54. 54. Patient selection
  55. 55. 4 Main Connections IVC Portal Vein Hepatic Atery Bile Duct
  56. 56. Indication : non-surgery HCC TYPE : • Radiofrequency ablation (RFA) • Microwave ablation • Chemical ablation
  57. 57. 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
  58. 58. 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
  59. 59. Transarterial Chemoembolisation (TACE)
  60. 60. TACE
  61. 61. 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.
  62. 62. 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
  63. 63. Physical examinations : • He was slender man without jaundice • Vital sign : normal • Perfomrmance status : 0 (Scale 0  5) • Physical examination revealed no abnormalities CASE REPORT
  64. 64. 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
  65. 65. • 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 ?
  66. 66. Pathology
  67. 67. DEFINITIVE DIAGNOSIS • Hepatocellular Carcinoma Stage A followed BCLC 2018
  68. 68. + Tumor resection IV, V, VIII + Tx HBV infection + Supportive care Following - up: + AFP : 3 – 6 month + US : 6 month TREATMENT
  69. 69. 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

Chẩn đoán và chiến lược quản lý ung thư gan Tài liệu mang tính chất tham khảo

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