Hepatocellular Carcinoma

Hepatocellular Carcinoma (HCC) – Julie Cui

Background

  • Pts with HCV cirrhosis are at greatest risk (incidence 2-4% per year)
  • In chronic HBV, pts can develop HCC without having cirrhosis, as can patients with NASH

 

Evaluation

  •  Regular screening in pts w/ cirrhosis HCC
  • Also recommended to screen non-cirrhotic with chronic HBV
    • U/S every 6 months (w/ or w/o AFP)
    • Routine screening with CT or MRI is not recommended
  • Options If U/S not satisfactory:
    • CT A/P w/contrast, in comments specify triple phase for HCC screening
    • MRI, specify Gadovist (preferred contrast agent)
    • Contrast-enhanced ultrasound
  • AFP trend is more useful than 1 value in time, though AFP >20 should prompt multiphase CT or MRI for further evaluation
  • Diagnosis can be made either by imaging (most common) or biopsy (rarely).
    • Triple phase CT demonstrates strong early uptake in arterial phase, with subsequent wash-out in portal-venous phase
    • If diagnosis remains unclear: can surveillance imaging or biopsy
    • LI-RADS system notes risk of malignancy based on imaging characteristics

 

LI-RADS

What does it mean?

What do we do?

LR-1 to LR-2

Definitely/Probably benign

Routine surveillance, consider diagnostic imaging within 6 mos

LR-3 to LR-4

Indeterminate/Probably HCC

Repeat or alternative diagnostic imaging in 3-6 mos. Consider Bx for LI-RADS 4

LR-5

Definitely HCC

Plan treatment as noted below

LR-M

Cancer but may not be HCC

  


Management

  • Lesions that meet Milan criteria can qualify for MELD exception points and are considered transplant candidates
    • This accounts for pts w/minimal synthetic dysfunction (and therefore low MELD)
  • Milan criteria:
    • Single tumor with diameter >2cm but <5 cm, no more than 3 tumors, each <3 cm
    • No signs of extra-hepatic involvement or vascular invasion
  • Pts may remain transplant candidates if rx downstages their HCC to meet above criteria
  • Liver transplant is definitive treatment, although resection can also be curative
    • Favored in pts w/early cirrhosis (Child Pugh A) and HCC amenable to resection
  • Locoregional therapies: Pts w/ unresectable disease, or who are not surgical candidates

 

Therapy

Details

Radiofrequency ablation

If in a favorable location and size, IR can percutaneously ablate with a large needle that emits microwave frequencies

Trans-arterial chemoembolization (TACE)

Chemotherapeutic agents injected into the tumor to occlude the feeding blood supply to the area.

Trans-arterial radioembolization (TARE)

Like TACE, though radioactive compound (i.e. Y-90) used to occlude the feeding blood supply.

Stereotactic body Radiation Therapy (SBRT)

Radiation therapy: can be used as an alternative to ablation and is generally performed in those meeting Milan criteria

Systemic Chemotherapy

For metastatic disease