1. Hepatocellular carcinoma related to Hbv and Hcv

2. Hepatocellular carcinoma is the 5th most common malignancy worldwide with male-to-female ratio
5:1 in Asia
2:1 in the United States
Tumor incidence varies significantly, depending on geographical location.
HCC with age.
53 years in Asia
67 years in the United States.

3. Incidence according to etiology

4. Etiology Hepatitis B -increase risk 100 -200 fold Hepatitis C
Cirrhosis
- 70% of HCC arise on top of cirrhosis
Toxins -Alcohol Tobacco - Aflatoxins
Autoimmune hepatitis
States of insulin resistance- Overweight in males Diabetes mellitus

5. Signs & symptoms Nonspecific symptoms Physical findings abdominal pain
Fever, chills
anorexia, weight loss
jaundice
Physical findings
abdominal mass in one third
splenomegaly
ascites
abdominal tenderness

6. which patients are at high risk for the development of HCC & should be offered surveillance
- M &F with established cirrhosis due to HBV and/ or HCV, particularly those with ongoing viral replication
- M &F with established cirrhosis due to genetic haemochromatosis
- M with alcohol related cirrhosis
- M with primary biliary cirrhosis

7. Patient who require surveilance
Asian men > 40 y (HBV chronic hepatitis)
Asian women> 50 y
Family history of Hcc
Cirrhotic patient
African and and north American black

8. Screaning
Patient with hbv who are African appear to get hcc at a younger age

9. Risk factor for hbv Host Male ( estrogen and testosterone )
Family history of hcc
Cirrhosis
obesity

10. virus Elevated hbv DNA level Hbe Ag Genotype C and D
HDV , HIV , or HCV co-infection

11. Environmental
Alcohol
Tobacco ( smoking)
Aflatoxin B

12. Because hcc may develop in chronic hbv in the absence of cirrhosis , many patients may have had preserved liver function and thus been able to tolerate resection.

13. hcc
Genotype 1b
HCV RNA level

14. diagnosis
Ultra sonography
AFP

15. End stage of cirrhosis(prognosis)

17. Treatment/Managmenttement

18. Treatment (Surgery)
The only proven potentially curative therapy for HCC
Hepatic resection or liver transplantation
Patients with single small HCC (≤5 cm) or up to three lesions ≤3 cm

19. Resection
Hepatic resection should be considered in HCC and a non-cirrhotic liver (including fibrolamellar variant)
Resection can be carried out in highly selected patients with cirrhosis and well preserved hepatic function (Child-Pugh A) who are unsuitable for liver transplantation. It carries a high risk of postoperative decompensation.
The majority of early mortality is due to liver failure.

20. Transplantation
Liver transplantation should be considered in any patient with cirrhosis

21. Transplantation Milan Criteria : Single HCC ≤5 cm or
Up to three nodules ≤3 cm
No extra hepatic spread
About 10 % qualify for listing
The major drawback of transplantation is
The scarcity of donors.
The long waiting time.

22. Treatment (non-Surgical)
should only be used where surgical therapy is not possible.
Percutaneous ethanol injection (PEI)
has been shown to produce necrosis of small HCC.
It is best suited to peripheral lesions, less than 3 cm in diameter
Radiofrequency ablation (RFA)
High frequency ultrasound to generate heat
good alternative ablative therapy
No survival advantage
Useful for tumor control in patients awaiting liver transplant

23. Treatment (non-Surgical
3) Cryotherapy
intraoperatively to ablate small solitary tumors outside a planned resection in patients with bilobar disease
4) Chemoembolisation
Concurrent administration of hepatic arterial chemotherapy (doxirubicin) with embolization of hepatic artery
Produce tumour necrosis in 50% of patients
Effective therapy for pain or bleeding from HCC
Affect survival in highly selected patients with good liver reserve
Complications: (pain, fever and hepatic decompensation)

24. Treatment (non-Surgical
5) Systemic chemotherapy
very limited role in the treatment of HCC with poor response rate
Best single agent is doxorubicin (RR: %)
should only be offered in the context of clinical trials
6) Hormonal therapy
Nolvadex, stilbestrol and flutamide
7) Interferon-alfa
8) retinoids and adaptive immunotherapy (adjuvant)

25. Radiofrequency Ablation

27. Transarterial Chemoembolization
Meta-analysis of 7 randomized controlled trials
2 yr survival: 41% (19-63%)
Treatment response: 35% (16-61%)
Average no. of sessions: 1-4.5
Risks:
Infection
Tumor lysis syndrome
Hepatic failure