Hepatocellular Carcinoma (HCC)¶
Julie Cui
Background¶
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Fifth most common tumor and the second most common cause of cancer related death worldwide
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The incidence in patients with cirrhosis is 2-4% per year
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In chronic HBV and NASH, pts can develop HCC without having cirrhosis
Evaluation¶
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Regular screening in pts with cirrhosis (or chronic HBV without cirrhosis) for HCC
- RUQ U/S q6mo (with or without AFP)
- Routine screening with CT or MRI is not recommended
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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
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AFP trend is more useful than one value in time, though AFP >20 should prompt multiphase CT or MRI for further evaluation
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Diagnosis can be made either by imaging (most common) or biopsy (rare)
- 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
| 0 | 1 | 2 |
|---|---|---|
| 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 | NaN |
Management¶
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Lesions that meet Milan criteria can qualify for MELD exception points and are considered transplant candidates
- This accounts for pts with minimal synthetic dysfunction (and therefore low MELD)
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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
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Liver transplant is definitive treatment, although resection can also be curative (favored in pts with early cirrhosis i.e. Child Pugh A)
- Locoregional therapies: Pts with unresectable disease, or who are not surgical candidates
| 0 | 1 |
|---|---|
| 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 |