ISG MASTERCLASS I: (11) Management of HCC

Management of HCC
Dr Anil Arora

[khaliddurrani]

Excellent overview of an imp yet complex disease.
The revised BCLC ( 2020 ) includes upto 5 cm single lesion in A stage and following liver directed therapy stage B disease may be eligible for curative therapy.
Whereas BCLC is followed in the west, it’s considered restrictive as regards surgery / curative therapy in Asia. Several Asian centers have given their own staging & management algorithms ie Korea, Japan, China, Hong Kong.
In the developing countries with limited facilities for transplant liver resection of operable intermediate stage hcc would be highly desirable.
Finally an HPB surgeon to highlight the role of Surg, the only curative option would have been appropriate.

[temesgenteferabekele]

🎯 Key Takeaways for quick navigation:

00:11 🎙️ *The 11th ISC Masterclass focuses on managing hepatocellular carcinoma (HCC).*
01:16 🗣️ *Dr. Anil Arora, a renowned speaker from Sir Ganga Ram Hospital, discusses HCC management, emphasizing prevention.*
08:29 🕵️ *Surveillance for HCC is essential, with criteria including commonality, affordability, acceptability, and effectiveness.*
11:26 🌐 *Ultrasonography is a key surveillance modality, offering high sensitivity in detecting early HCC, especially in countries like Japan.*
13:03 📸 *Radiological diagnosis of HCC, using criteria like arterial phase hyperenhancement, can often eliminate the need for a tissue biopsy.*
15:47 ⚖️ *Biopsy is indicated for indeterminate lesions, and staging considers tumor size, performance status, and liver function.*
19:15 🚑 *Curative therapies for early HCC include ablation, surgery, and liver transplantation, with options like percutaneous ethanol injection and radiofrequency ablation.*
21:10 ❓ *Radiological diagnosis of HCC includes arterial hyperenhancement, total venous washout, and underlying cirrhosis, but not a size less than one centimeter.*
24:57 🩺 *Early diagnosis of HCC involves recognizing well-differentiated carcinoma and assessing fat positivity. PET has no role in early HCC diagnosis.*
25:41 🔄 *Surveillance for HCC in non-cirrhotic patients with portal hypertension depends on thrombosis presence; hypercoagulable state may be a focus.*
26:09 🌐 *BCLC staging system, particularly BCLC, is widely used in India for HCC, validated and considered best. The speaker suggests an easier algorithm as an alternative.*
27:17 🩸 *Larger HCCs, preserving liver function, may not exhibit elevated alpha-fetoprotein. Surgery is the primary curative option, with no significant difference in radiological features based on cirrhosis presence.*
28:13 📉 *AFP of 170 in a <1 cm dysplastic nodule poses a challenge. Replication status check is crucial; if positive, follow-up; if negative, consider further imaging after 2 cm.*
29:30 📊 *Surgical resection for HCC depends on the number, extent of lesions, and Child-Pugh or MELD scores, ensuring low mortality and morbidity.*
31:39 ⚖️ *RFA is comparable to local resection for lesions up to 3 cm. Criteria for major or minor resection depend on portal hypertension and liver function.*
32:18 🔄 *Liver transplantation, particularly meeting Milan's criteria, is a curative option for HCC. Living donor liver transplantation has expanded criteria, including UCSF criteria.*
34:51 🎯 *For multinodular, unresectable HCC with preserved liver function (BCLC B), transarterial chemoembolization (TACE) is a classical local-regional therapy.*
38:23 🎯 *Transarterial radioembolization (TARE) uses microspheres to target hepatocellular carcinoma, showing potential advantages but not universally recommended over TACE.*
39:45 🌐 *Systemic therapy considerations involve sequential use of sorafenib and lenvatinib. Immunotherapy, particularly immune checkpoint inhibitors, shows promise.*
43:44 🤝 *Prevention of HCC includes lifestyle modifications, hepatitis B vaccination, and treating hepatitis B and C. Coffee consumption may reduce HCC risk.*
44:52 🧬 *Liquid biopsy, detecting tumor-associated protein biomarkers and genomic patterns in extracellular vesicles, shows promise for early HCC diagnosis.*
51:43 🩹 *Use of TCP and Alpha-fetoprotein fraction L3 in management helps characterize lesions likely to recur, guiding decisions on liver transplantation.*
52:25 🧐 *CT, MRI, and EUS are crucial for distinguishing multicentric HCC from a single HCC with multiple intrapatic metastases. Prior imaging history is essential for accurate diagnosis.*
53:54 🚫 *Non-cirrhotic HCC requires biopsy for diagnosis, as radiological criteria are specified only for cirrhosis cases. Three requisites include underlying cirrhosis, lesion >1cm, and arterial enhancement with venous washout.*
54:50 🩸 *Fibroscan's role in HCC diagnosis is minimal, and its advantage diminishes after obtaining CT and MRI results. Diagnosis is effectively done through CEUS, CT scan, and MRI.*
55:31 📊 *Comparison of Hong Kong (HKLC) and Barcelona Clinic (BCLC) liver cancer scores in Indian patients varies across centers. Validation is needed, and deviations require prospective evaluation.*
57:24 🔄 *Post-SVR HCV cirrhosis surveillance frequency should remain consistent. Starting direct-acting antivirals (DAAs) at HCC diagnosis aids recovery, reducing subsequent HCC development.*
59:06 💡 *Surveillance strategy for alcoholic cirrhosis and NASH cirrhosis aligns with incidence and cost-effectiveness. Non-cirrhotic NASH surveillance is subjective, considering individual factors.*
01:00:17 🔄 *HCC management algorithm: Begin by assessing performance status (PS), presence of extrahepatic spread, and lesion size in Milan criteria. Tailor treatment based on PS, tumor size, and underlying cirrhosis.*
01:06:28 ☕ *Coffee reduces oxidative stress, potentially lowering HCC risk. Its impact is associated with stimulating MAPK3 kinase and decreasing inflammation caused by etiological agents.*
01:08:10 🚫 *Sorafenib's efficacy in HCC treatment is not significantly enhanced by adding statins. Clear risk reduction data is lacking for statins in HCC prevention.*
01:08:59 📊 *Des-γ-carboxy prothrombin (DCP) and Alpha-fetoprotein fraction L3 have limited roles in HCC diagnosis but play a crucial role in prognosis, guiding decisions on surgery, recurrence, and transplantation.*
01:09:12 🩸 *In pediatric HCC, management approach is uncertain due to limited experience. Liquid biopsy, recently published, may provide additional diagnostic insights.*

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