HEPATOCELLULAR CARCINOMA

INDICATIONS FOR SURGERY By

Dr E Aravind

Most common primary liver malignancy Most common of the solid organ cancers Surgery is potentially curative But discovered at a stage too advanced

for complete excision Highly resistant to chemotherapy,

limiting options for palliative treatment.

Difficulties in treatment due toUsually asymptomatic at early stagesAssociated with cirrhosisIntravascular or intrabiliary extension

Important aspect of the morbidity, mortality, and long-term outcome of liver resection depends on patient selection

Treatment depends on tumor stage and the functional status of the liver

Classified into three distinct patterns of growth that are associated with resectabilityHanging typePushing typeInfiltrative type

TUMOR STAGE Done by triphasic CT

Number Size Presence of satellite nodules Tumor invasion of the portal vein, its branches, or

the inferior vena cava; To exclude any extrahepatic metastasis; for

surgical planning, Clarify the relationship of the tumors with the

intrahepatic vascular and biliary structures MRI is contrast is contrindicated

EVALUATION OF LIVER FUNCTION Accurate evaluation of the liver

functional reserve is therefore crucial to avoid postoperative hepatic insufficiency

Child-Turcotte-Pugh(Child) classification is used for evaluation of liver function

partial hepatectomy is offered only to patients who are Class A

Most favourable Class B patients. Class C patients are only offered

supportive care,

Indocyanine green (ICG) clearance testICG retention rate at 15 minutes (ICG R15)

of 10% to 20% is considered the upper limit Hepatic venous pressure gradient

(HVPG)indirect measure of portal hypertension>10 mm Hg - unresolved hepatic

decompensation

Model for End-Stage Liver Disease (MELD) scoreMELD = 3.78×ln[serum bilirubin (mg/dL)] +

11.2×ln[INR] + 9.57×ln[serum creatinine (mg/dL)] + 6.43×aetiology(0: cholestatic or alcoholic, 1: otherwise)

Scores of <9 predict both low mortality and reduced morbidity after hepatic resection

FUTURE LIVER REMNANT Actual total liver volume (TLV), defined as

the volume of the patients liver measured directly on CT images minus tumor volume

Estimated liver volume, an alternative method by which the total liver volume is calculated by a formula that relies on a linear correlation between TLV and body weight or body surface area in healthy subjects

Portal vein embolization (PVE)In candidates for hepatic resection with

insufficient future liver reFLR is <40% of TLVContraindications to PVE include tumor

invasion of the portal vein

Prognostic staging models Barcelona Clinic Liver Cancer (BCLC)

Early, Intermediate,Advanced, Terminal

Hepatic resection is indicated only in patients with early stage HCC defined byMilan criteria

○ single tumors ≤5 cm in maximal dimension or no more than three tumors each ≤3 cm in maximal dimension

Normal clinical performance status Preserved liver function (bilirubin levels <1

mg/dL, absence of portal hypertension, and Child-Pugh class A status)

Site of tumor Hepatic segments involved Feasibility when all tumor nodules can

be technically excised with negative margins while maintaining an adequately functioning hepatic remnant,

Clinical performance statusis >50% to 60% and systemic comorbidity is compensated

Contraindications for resectionExtrahepatic disease,Tumor thrombus in the inferior vena cava, Involvement of the common hepatic artery

and portal vein trunk

Total Hepatectomy and Liver Transplantation. Allows for tumor resection with the

widest possible margins, and permits removal of diseased and tumorigenic parenchyma that may contain microscopic metastatic disease and be predisposed to the formation of additional primary tumors.