LIVER CANCERSDr. MANISH DUTT

• ANATOMY

• EPIDEMIOLOGY

• ETIOLOGY

• PATHOLOGY

• PROGNOSTIC FACTORS

• WORKUP

• STAGING

anatomy

Couinaud segments

Clinical significance

Each segment can be resected without damaging those remaining

resections must proceed along the vessels

Dual blood supply:

Portal vein: 3/4

Hepatic artery:1/4

Venous outflow:

Hepatic veins: left, right and middle

Drains into IVC

HEPATIC LOBULES

EPIDEMIOLOGY• 782,000 new cases worldwide 2012

• fifth most common cancer in men, 7.5% of the total) and the ninth in women (3.4%)

• high incidence in Eastern and South-Eastern Asia (ASRs 31.9 and 22.2 respectively)

• lowest rates in Northern Europe (4.6) and South-Central Asia (3.70

• second most common cause of death from cancer 746,000 deaths in 2012 (9.1% of the total)

• prognosis very poor (overall ratio of mortality to incidence of 0.95

INDIAN STATS• men 0.9-7.5 per 100,000

• women 0.2 -2.2 per 100,000

• male:female ratio for HCC in India is 4:1

• age of presentation 40 to 70 years

• highest AAIR was reported from Sikkim(7.5)and Mizoram(6.4)

• 4–8% of the cancers were due to HCC

• annual incidence rate of 1.6% (Paul et al) in cirrhotics

• age standardized mortality rate for men is 6.8 ,women 5.1/100,000.

• incidence of HCC in cirrhotics in India is 1.6% per year

• 70–97% of patients with HCC at the time of diagnosis had underlying cirrhosis of liver

• incidence of HCC is increasing in India

ETIOLOGY

• Viral hepatitis- HBV

1. 98 fold greater risk

2. Asymptomatic HbsAg+ - 12 times RR

3. MECHANISM-indirect/direct

4. 70% HBV related HCC- with cirrhosis

5. Risk of HCC in hepB cirrhotic 0.5%

• HCV-

1. Chronic infection(60-80%)

2. 20 fold more and advanced cirrhosis

3. Risk of HCC in hepC cirrhotic 5%

Mi-R-155 accumulation

Etiology contd.• Alcohol- carcinogenic, acetaldehyde, oxidative stress

• NASH(24%)

• METABOLIC DISEASES-haemochromatosis, Wilson, alpha1 AT def.

• Chemical carcinogens- aflatoxin

• Anabolic steroids, estrogens

• Pesticides, insecticides

• Obesity, DM

• Cumulative tobacco use

• Male, old age, specific promotor mutations, higher viremia levels

STAGING

PROGNOSTIC FACTORS

• large size,

• multiple tumors

• vascular invasion

• lymph node spread

• Macroscopic or microscopic vascular invasions

• severity of underlying liver disease- CHILD PUGH, CLIP, V-CLIP, (JIS), BCLC

DIAGNOSTIC W/U

• Labs: CBC, LFTs, chemistries, coagulation panel, serum AFP(10–15% false negative), Hepatitis B/C panels.

• Abdominal CT scan (special contrast protocol).

• FNAC can be performed but is not always needed.

W/U Contd.

Radiological/non invasive

• Lesions>2cm-

• arterial hyperenhancement on two different imaging modalities, or on one imaging modality alongside with a serum AFP of 400 ng/dL

• both arterial hyperenhancement and venous washout in a single imaging modality concomitant with an AFP >200 ng/mL

• sensitivity and specificity of 64.9% and 62.8%

pathological

• Core biopsies- liver/portal vein

• stromal invasion

• sensitivity and specificity of 89.1% and 100%