Hepatocellular Carcinoma (HCC)

Julie Cui

Background

  • Fifth most common tumor and the second most common cause of cancer related death worldwide
  • The incidence in patients with cirrhosis is 2-4% per year
  • In chronic HBV and NASH, pts can develop HCC without having cirrhosis

Evaluation

  • 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
  • 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 one 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 (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

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 with 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
  • 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

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 artery to the area.
Trans-arterial radioembolization (TARE) Like TACE, though radioactive compound (i.e. Y-90) is Injected In the the feeding artery
Stereotactic body Radiation Therapy (SBRT) Radiation therapy: can be used as an alternative to ablation or trans-arterial therapy
Systemic Chemotherapy For metastatic disease
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