1. Hepatocellular carcinoma Diagnosis, Treatment, Prognosis + Quiz Vinko Bubic Mentor: A. Žmegač Horvat

2. Diagnosis Physical examination - enlarged, tender liver Elevated serum alpha fetoprotein (normally : 40mg/l) Elevated liver enzymes (ALT, AST, Alpha-1 antitrypsin, serum bilirubin, urine bilirubin...)

3. Diagnosis CT

4. Computed tomography - medical imaging method employing tomography (imaging by sections or sectioning) Large series of two-dimensional X-ray images taken around a single axis of rotation, computer integration Iodine dye through vein for better visualisation (allergy)

6. MRI Magnetic resonance imaging The body - mainly composed of water molecules Electromagnetic field causes protons to absorb some of its energy Scanner detects release of proton energy (tumor tissue releases different frequency) Greater contrast than CT

7. Modern 3T MRI

8. Biopsy Definitive diagnosis of hepatocellular carcinoma

9. Hyperchromatic, clear cells with large red cytoplasm

10. Treatment Liver transplatation (cadaver liver or live donor lobe) Surgical resection (best prognosis for long-term survival, but possible in only 10-15% of cases)

11. Treatment Percutaneus ethanol injection - small (< 3 cm) solitary tumors Transcatheter arterial chemoembolization (TACE) - more than 3 cm and less than 4 cm in diameter Sealed source radiotherapy (brachytherapy) - radioactive source is placed inside or next to area requiring treatment

12. Prior to ethanol ablationAfter

13. Transcatheter arterial chemoembolization

14. Other techniques Radiofrequency ablation (RFA) High intensity focused ultrasound (HIFU) Chemotherapy (antiestrogen + tamoxifen) Cryosurgery - destruction of abnormal tissue using sub-zero temperatures

15. HIFU

16. Cryosurgery Iceball

17. HCC complications Gastrointestinal bleeding Cachexy Portal hypertension -> esophageal bleeding Liver failure Metastasis (lymph nodes around pancreas, aorta, lungs, adrenal glands, bones) Rupture of tumor -> abdominal bleeding

18. Prognosis Usually poor outcome Only 10 - 20% of hepatocellular carcinomas can be removed completely If not, disease usually deadly within 3 to 6 months

19. Quiz: The definitive HCC diagnosis is confirmed by: a) spider nevus by inspection b) auscultation c) biopsy and microscopy d) MRI e) esophageal reflux

20. Ethanol: a) dehydrates cells b) hydrates cells and cracks them c) activates IL-8 d) causes apoptosis e) nothing from above

21. In cryotherapy, tumor is frozen by: a) flucloxacillin b) Iodine c) liquid nitrogen d) surgeon’s eye e) cocaine

22. What did you eat today? This maybe?

23. Thanks ! ! !

24. References: http://www.cancer.gov/cancertopics/types/liver/ http://www.mayoclinic.com/health/liver- cancer/DS00399 http://www.mayoclinic.com/health/liver- cancer/DS00399 Medicinski leksikon, Leksikografski zavod “Miroslav Krleža”, Zagreb 1992. PATOLOGIJA, urednici Damjanov, Jukic, Nola, izdanje 2007.