Dr Wong Jen-San Raffles Hospital. Courtesy of Prof Pierce Chow

Transcription

1 Dr Wong Jen-San Raffles Hospital Courtesy of Prof Pierce Chow 1

2 RHV 51 year old Child-Pugh A Hepatitis B + Platelet 278 CT: 6 cm HCC with extension of HCC into RPV and likely RHV RPV

3 a. Surgical Resection b. Chemoembolization (TACE) c. External beam radiation d. Selective internal radiation therapy (SIRT)* e. Sorafenib* * Not available in 2006

4 Segmental PVT Main PVT TACE median 10.2 months Conservative median 5.2 months TACE median 5.3 months Conservative median 3.4 months A prospective comparative study of TACE in PVT in Asia Luo et al 2011 Ann Surg Onc Pierce Chow FRCSE PhD 4

5 Outcomes of surgical resection for HCC with PVT Lau WY et al 2013 Oncology Variable data for PVT little data for hepatic vein but this case was in

6 LOCALLY ADVANCED HEPATOCELLULAR CARCINOMA Clinical Presentation Treatment Options Consider Clinical Trial Locally Advanced HCC Good liver function Poor liver function Present for evaluation by multi-disciplinary team - Palliative treatment - Consider Clinical Trial - Transplant within UCSF Surgical resection for carefully selected cases after multidisciplinary board evaluation LOCOREGIONAL THERAPY No Vascular Invasion* Transarterial chemoembolisation (TACE) + DC-Beads [32,33] (level 1b) Selective Internal Radiation Therapy (SIRT) [34-36] (level 2b) External beam RT (alone or as part of combined modality) Sorafenib [32-35] (level 1b) With Vascular Invasion Sorafenib [37-40] (level 1b) Selective Internal Radiation Therapy (SIRT) [34-36] (level 2b) External beam RT (alone or as part of combined modality) [41,42] (level 2a) Transplantation is a consideration for HCC within the USCF expanded criteria (single tumours < 6.5cm or 2-3 tumours < 4.5cm at the most, with a total tumour diameter < 8cm) after assessment by a multidisciplinary tumour board [43,44] (level 2b) *Sorafenib may also be considered when local regional therapy is not feasible or fails [40] (level - 2b) National Cancer Center Singapore Consensus Guidelines on Liver Cancer guideline Final Ver to upload PDF pdf

7 Right hepatectomy 28/7/06 6 cm HCC at segment VI of liver Histopathology: HCC with intra-parenchymal extension into portal vein and hepatic vein 7

8 F/u CT (27/6/08): Interval multiple arterial-enhancing lesions with washout, compatible with multifocal recurrent HCC 8

9 a. Chemoembolization (TACE) b. Selective internal radiation therapy (SIRT) c. Surgical Resection d. Liver transplantation (but way beyond Milan criteria) e. Radio-frequency Ablation (> 3 lesions) f. Sorafenib (just became available in 2008)

10 Sangro European patients Mainly Hepatitis C/alcohol Median Survival: 12.8 months (95% CI: ) BCLC B: 16.9 months BCLC C: 10.0 months Failed or progressed on prior therapy 41.5% Trans-arterial therapy 27.4% Surgery/transplantation 18.2% Percutaneous ablative therapy 9.2%

11 Khor Singapore patients Mainly Hepatitis B Median Survival: 14.4 months (95% CI, ) BCLC B: 23.8 months BCLC C: 11.8 months Failed or progressed on prior therapy 55.4% Trans-arterial therapy 17.5% Surgery/transplantation 14.6% Percutaneous ablative therapy 12.6% Chemotherapy 10.7%

12 LOCALLY ADVANCED HEPATOCELLULAR CARCINOMA Clinical Presentation Treatment Options Consider Clinical Trial Locally Advanced HCC Good liver function Poor liver function Present for evaluation by multi-disciplinary team - Palliative treatment - Consider Clinical Trial - Transplant within UCSF Surgical resection for carefully selected cases after multidisciplinary board evaluation LOCOREGIONAL THERAPY No Vascular Invasion* Transarterial chemoembolisation (TACE) + DC-Beads [32,33] (level 1b) Selective Internal Radiation Therapy (SIRT) [34-36] (level 2b) External beam RT (alone or as part of combined modality) Sorafenib [32-35] (level 1b) With Vascular Invasion Sorafenib [37-40] (level 1b) Selective Internal Radiation Therapy (SIRT) [34-36] (level 2b) External beam RT (alone or as part of combined modality) [41,42] (level 2a) Transplantation is a consideration for HCC within the USCF expanded criteria (single tumours < 6.5cm or 2-3 tumours < 4.5cm at the most, with a total tumour diameter < 8cm) after assessment by a multidisciplinary tumour board [43,44] (level 2b) *Sorafenib may also be considered when local regional therapy is not feasible or fails [40] (level - 2b) National Cancer Center Singapore Consensus Guidelines on Liver Cancer guideline Final Ver to upload PDF pdf

13 Underwent Selective Internal Radiation Therapy with yttrium-90 8/7/08 13

14 Jun 08 Aug 09 Liver remains tumor free today 14

15 August 2009 Mass right jaw PET: No other metastatic lesion Segmental mandibulectomy and SCM flap 4/9/09 Histology: metastatic HCC 15

16 Sept 2010 Left flank pain and hemodynamic shock PET: No other metastatic lesion 16

17 Left adrenalectomy and evacuation of hematoma 7/10/10 17

18 July 2013 Multiple lung metastases sorafenib Patient still alive enrolled in clinical trial in NCC 18

19 METATASTIC HEPATOCELLULAR CANCER Clinical Presentation Treatment Options Patients with good liver function (Child-Pugh A or B) Systemic therapy Metatastic HCC Present for evaluation by Multi-disciplinary team at TBM Consider biopsy to confirm metastatic disease Sorafenib (Child-Pugh Class A or B) [37,45] (level 1b) Consideration for clinical trial Palliative RT as appropriate Patients with poor liver function Best supportive care Consideration for clinical trial Palliative RT as appropriate ) [29] (level 2a)

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