1. HEPATIC TUMORS Dr.Cengiz Pata Gastroenterology Department Yeditepe University,Istanbul

2. clasification Primer malign tumors HEPATOCELLULER CA HEPATOCELLULER CA HEPATOBLASTOMA HEPATOBLASTOMA ANGİOSARCOMA ANGİOSARCOMA Seconder malign tumors METASTATİC METASTATİC Benign tumors HEPATOCELLULER ADENOMA HEPATOCELLULER ADENOMA CAVERNOUS HEMANGİOMA CAVERNOUS HEMANGİOMA HEMANGİOENDOTHELİOMA HEMANGİOENDOTHELİOMA FOCAL NODULER HYPERPLASİA FOCAL NODULER HYPERPLASİA

3. HEPATOCELLULER CARCİNOMA Clinical Presentation Worldwide, over 1 million cases of HCC occure every year. Worldwide, over 1 million cases of HCC occure every year. The incidence of HCC is higher in areas of the world that have high hepatitis B and C carrier rates. The incidence of HCC is higher in areas of the world that have high hepatitis B and C carrier rates. HCC typically develops in the setting of chronic liver disease or cirrhosis. HCC typically develops in the setting of chronic liver disease or cirrhosis.

5. Risk factors for HCC Hepatitis B carrier Hepatitis B carrier Chronic hepatitis C viral infection Chronic hepatitis C viral infection Alfatoxin Alfatoxin Chronic hepatitis ( any cause ) Chronic hepatitis ( any cause ) Cirrhosis ( any cause ) Cirrhosis ( any cause ) İnactive viral enfection İnactive viral enfection

6. Clinical Presentation Not uncommonly, HCC present without symptoms other than those related to the chronic liver disease or cirrhosis. Not uncommonly, HCC present without symptoms other than those related to the chronic liver disease or cirrhosis. HCC should be suspected in cirrhotic patients who present with any of the fallowing: HCC should be suspected in cirrhotic patients who present with any of the fallowing: 1. Deterioration in liver function 1. Deterioration in liver function 2. Acute complication ( ascites, variceal bleed, jaundice, encephalopathy) 2. Acute complication ( ascites, variceal bleed, jaundice, encephalopathy)

7. Symptoms Right upper quadrant pain Right upper quadrant pain Right shoulder pain ( suggestive of diaphragmatic involvement ) Right shoulder pain ( suggestive of diaphragmatic involvement ) Acute abdominal pain ( tumor rupture or hemorrhage ) Acute abdominal pain ( tumor rupture or hemorrhage ) Fatigue Fatigue Anorexia Anorexia Weight loss Weight loss Fever Fever Night sweats Night sweats

8. Signs Hepatomegaly Hepatomegaly Abdominal mass Abdominal mass Ascites ( rapid progression suggests Budd-Chiari syndrome ) Ascites ( rapid progression suggests Budd-Chiari syndrome ) Bruit ( heard over the liver, occasional finding ) Bruit ( heard over the liver, occasional finding ) Physical exam finding related to the chronic liver disease or cirrhosis ( eg, jaundice ) Physical exam finding related to the chronic liver disease or cirrhosis ( eg, jaundice )

9. Laboratory Testing-1 Liver function test abnormalities consistent with cirrhosis are frequently present since most HCC arise in the setting of cirrhosis: Thrombocytopenia Thrombocytopenia Hypoalbuminemia Hypoalbuminemia Increased PT Increased PT Increased Bilirubin Increased Bilirubin Normal or mild increase in transaminase levels Normal or mild increase in transaminase levels Normal or increased ALP level Normal or increased ALP level

10. Laboratory Testing-2 %75-90 of patients with HCC have an elevated AFP level. AFP levels may be elaveted other hepatic diseases such as hepatitis ( acute or chronic ) and cirrhosis. AFP levels may be elaveted other hepatic diseases such as hepatitis ( acute or chronic ) and cirrhosis. Many experts maintain that an AFP level > 500  g/L is diagnostic for HCC in a patient who is at risk for this type of cancer. Many experts maintain that an AFP level > 500  g/L is diagnostic for HCC in a patient who is at risk for this type of cancer. In patients who have AFP elevation due to HCC, the degree of elevation is not related to the stage of the tumor, size of the lesion, or prognosis of the patient. In patients who have AFP elevation due to HCC, the degree of elevation is not related to the stage of the tumor, size of the lesion, or prognosis of the patient. With tumor resection, AFP levels often return to normal. With tumor resection, AFP levels often return to normal. AFP levels are useful in monitoring patients for tumor recurrence following tumor resection. AFP levels are useful in monitoring patients for tumor recurrence following tumor resection.

11. Ultrasonography Small tumors are often hypoechotic but with growth, the tumor is more likely to be isoechotic or even hyperechotic. US findings that are particulary suggestive of the diagnosis are ill-defined margins and coarse, irregular internal echoes. Small tumors are often hypoechotic but with growth, the tumor is more likely to be isoechotic or even hyperechotic. US findings that are particulary suggestive of the diagnosis are ill-defined margins and coarse, irregular internal echoes. Will identify most HCC but cannot reliably distinguish these lesions from other hepatic lesions. As a result, other imaging test modalities are often necessary. Will identify most HCC but cannot reliably distinguish these lesions from other hepatic lesions. As a result, other imaging test modalities are often necessary. The detection of a hepatic mass in combination with an AFP level > 500 mg/L is considered to be diagnostic for HCC. The detection of a hepatic mass in combination with an AFP level > 500 mg/L is considered to be diagnostic for HCC. Percutaneous ultrasound-guiged FNA of a liver mass can be done to establish the diagnosis but complications include hemorrhage and tumor seeding. Percutaneous ultrasound-guiged FNA of a liver mass can be done to establish the diagnosis but complications include hemorrhage and tumor seeding.

12. CT-Scan ( With intravenous contrast ) Can identify tumors < 1 cm. Can identify tumors < 1 cm. CT scan has greater sensivity and spesificity than US, especially for tumors < 1 cm. CT scan has greater sensivity and spesificity than US, especially for tumors < 1 cm. CT is often done to evaluate an abnormality first detectedon US. In some centers, however, it is the initial imaging modality in the patient suspected of having HCC. CT is often done to evaluate an abnormality first detectedon US. In some centers, however, it is the initial imaging modality in the patient suspected of having HCC. Percutaneous CT-guiged FNA of a liver mass can be done to establish the diagnosis but complications include hemorrhage and tumor seeding. Percutaneous CT-guiged FNA of a liver mass can be done to establish the diagnosis but complications include hemorrhage and tumor seeding.

13. MRI Sensitivity of MRI is similar to that of helical CT. Sensitivity of MRI is similar to that of helical CT. Nonetheless, CT is preferred over MRI because of cost. Nonetheless, CT is preferred over MRI because of cost. Consider MRI over CT scan if patient has renal insufficiency, allergy to contrast dye, or CT results that are equivocal. Consider MRI over CT scan if patient has renal insufficiency, allergy to contrast dye, or CT results that are equivocal.

14. Paraneoplastic manifestations Hypoglycemia Hypoglycemia Polycthemia Polycthemia Hypercalcemia Hypercalcemia Sexual changes Sexual changes Arterial hypertension Arterial hypertension Diarrhe Diarrhe Porphyria Porphyria Carcinoid syndrome Carcinoid syndrome Osteoperosis Osteoperosis Tyhrotoxicosis Tyhrotoxicosis Polymyositis Polymyositis Cutaneos markers: pitriasis rotunda, dermatomyositis Cutaneos markers: pitriasis rotunda, dermatomyositis

15. Okuda Staging System for HCC CriteriaPositiveNegative Tumor size >%50 < %50 Ascites Clinically detectable Clinically absent Albumin < 3 mg/dL > 3 mg/dL Bilirubin < 3 mg/dL

16. Staging Stage I Stage I No positives from the above table No positives from the above table ( median survival 8.3 months ) ( median survival 8.3 months ) Stage II Stage II One or two positives from the above table One or two positives from the above table ( median survival 2 months ) ( median survival 2 months ) Stage III Stage III Three or four positives from the above table Three or four positives from the above table ( median survival 0.7 months ) ( median survival 0.7 months )

17. Adverse Prognostic Factors Advanced age Advanced age Male sex Male sex Jaundice Jaundice Anorexia Anorexia Poor performance status Poor performance status

18. treatment Surgical Surgical-resection-transplantation Nonsurgical Nonsurgical -cheomtherapy (adriamycine, SORAFENİB) -TACE (lipiodol, gelfoam ) -ethonol injection -RF, cryosurgery

19. Treatment-1 Surgical resection should be considered if the HCC is resectable and the patient is a candidate for resection. Surgical resection should be considered if the HCC is resectable and the patient is a candidate for resection. 1. The likelihood that resction will succesfull depends upon the size ( < 5 cm ) and location of the tumor. In addition, success is also dependent upon whether the remaining hepatic parenchyma compensate for that which is resected 1. The likelihood that resction will succesfull depends upon the size ( < 5 cm ) and location of the tumor. In addition, success is also dependent upon whether the remaining hepatic parenchyma compensate for that which is resected 2. Ideal candidate has a solitary mass that does not invade the vasculature, good hepatic function, and no portal hypertension. 2. Ideal candidate has a solitary mass that does not invade the vasculature, good hepatic function, and no portal hypertension. 3. Lobar resection can often be performed in patients with Child’s class A cirrhosis. 3. Lobar resection can often be performed in patients with Child’s class A cirrhosis. 4. Because of the high recurrence rate after resection, postoperative adjuvant therapy should be considered. 4. Because of the high recurrence rate after resection, postoperative adjuvant therapy should be considered.

20. Treatment-2 Orthoptic liver transplantation has had promising results in the treatment of HCC but is limited by the long wait that is often needed for the donor liver. Orthoptic liver transplantation has had promising results in the treatment of HCC but is limited by the long wait that is often needed for the donor liver. Percutaneous ethanol injection and radiofrequency ablation should be considered in patients with HCC who cannot withstand resction because of poor hepatic reserve. Percutaneous ethanol injection and radiofrequency ablation should be considered in patients with HCC who cannot withstand resction because of poor hepatic reserve. Transarterial chemoembolization can be considered in patients with large, unresectable HCC. Transarterial chemoembolization can be considered in patients with large, unresectable HCC. Systemic chemotherapy and radiotherapy of limited benefit in HCC. Systemic chemotherapy and radiotherapy of limited benefit in HCC.