Risk factor of HCC
Hep B/ C
Liver cirrhosis
Alcohol
NAFLD
Hereditary hemochromatosis
Autoimmune hepatitis
Metabolic liver disease
What is the diagnostic CT feature for HCC?
Arterial enhancement with rapid washout in portal venous phase
Explain why HCC exhibit arterial enhancement and portal venous washout?
HCC has arterial supply which makes up only 30% of liver arterial supply, thus HCC will light up in arterial phase and contrast will leave HCC while normal parenchyma received major supply of blood from portal venous system
What is Child Pugh criteria?
Clinical criteria to predict mortality of cirrhotic patients
What are the components of Child Pugh criteria?
Albumin
Bilirubin
INR
Ascites
Hepatic Encephalopathy
What accumulated points signify a Grade A Child Pugh and what is the associated one year survival rate?
5-6 points
Well compensated disease
1 year survival rate 100%
What accumulated points signify a Grade B Child Pugh and what is the associated one year survival rate?
7-9 points
significant functional compromise
1 year survival rate of 80%
What accumulated points signify a Grade C Child Pugh and what is the associated one year survival rate?
10-15 points
Decompensated disease
40% 1 year survival
What does an ICG 15 min retention rate >14% signify?
Cannot withstand a formal/ extended hepatectomy
What is a normal ICG retention rate?
4%
Milan’s criteria
Criteria used to evaluate patients for orthopic liver transplantation
- Solitary tumor <5cm
- Multifocal < 3cm, each < 3cm
- No gross vascular invasion or regional/distant metastasis
Curative treatments for HCC
Resection
Local ablation
Transplant
What are the phases in a triphasic scan?
Non-contrast
Arterial phase
Portal venous phase
What is MELD?
Model for End Stage Liver Disease
Assesses severity of liver disease, predicts 3 month mortality
How to calculate MELD?
Serum creatinine
Total bilirubin
INR
- >15 benefit from transplant
- >9 higher perioperative mortality 30%
What is the adequate future liver remnant in CT volumetry
Normal liver: 20%
Post-chemo: 30%
Cirrhotic liver: 40%
Indications for liver transplantation in HCC
- Child C
- Meets Milan criteria
Arguments for liver transplantation in HCC
- Pros:
- better survival
- lower recurrence
- treats liver cirrhosis
- Cons:
- severe shortage of grafts
- lengthens waiting list in cases where resection can be done
- treatment morbidity & mortality
What types of bridging therapy are there prior to transplantation?
- TACE
- Ablation
- Resection
Reduces dropout rate due to tumor growth with long waiting times > 6 months
UCSF criteria
- Single nodule ≤ 6.5 cm or
- 3 nodules ≤ 4.5 cm and with a total volume no greater than 8 cm
- Give similar result to Milan’s
Indications for percutaneous ablation in HCC
- Curative
- Child’s A/B
- small HCC < 2-3 cm
- Palliative
- Child’s A/B
- solitary tumor <5 cm
- two to three nodules < 3cm
Arguments of RFA vs Resection in resectable tumors
Resection better long term overall survival
RFA better if borderline liver function, lower post tx complications, shorter hospital stay but incomplete clearance of tumor at specific sites of liver
What is radio-frequency ablation?
High frequency radiowaves delivered through needle electrode to destroy tumor by local heating
HIFU
High Intensity Focused Ultrasound
- extracorporeal
- non-invasive
well tolerated in advanced cirrhosis and gross ascites
