Hepatocellular Carcinoma: What the hepatologist wants to know

Transcription

1 Hepatocellular Carcinoma: What the hepatologist wants to know Hélène Castel, MD Liver Unit Hôpital St-Luc CHUM? CAR Annual Scientific Meeting Saturday, April 27 th 2013

2 Disclosure statement I do not have an affiliation, financial or otherwise, with a pharmaceutical company, medical device or communications organization. I have no conflicts of interest to disclose ( i.e. no industry funding received or other commercial relationships). I have no financial relationship or advisory role with pharmaceutical or device-making companies, or CME provider. I will not discuss or describe in my presentation at the meeting the investigational or unlabeled ("off-label") use of a medical device, product, or pharmaceutical that is classified by Health Canada as investigational for the intended use.

3 Learning objectives At the conclusion of this session, participants should be able to: 1. Discuss the HCC management guidelines. 2. Recognize the hierarchy of treatment in the BCLC staging system. 3. Identify the role of the radiologist in the clinical management of HCC.

4 Burden of HCC 6 th most frequent cancer 3 rd cause of death by cancer AASLD Guidelines on the Management of HCC. 2010

5 Trends in the diagnosis of HCC Categorization of nodules (<2 cm) as pre-neoplastic lesions or early HCC remains a diagnostic challenge

6 Tumor staging and prognosis score Coexistence of two life-threatening conditions

7 Tools for staging and treatment of HCC Tumor staging: -size -number -vascular invasion -extra hepatic disease Liver function, Portal hypertension Clinical performance status Liver biopsy Biological markers (AFP) Minimum If needed Treatment allocation prognostic prediction

8 Tumor staging and prognosis score CLIP* Tumor stage Tumor morphology, AFP, vascular invasion Liver function Health status Child - GRETCH vascular invasion, AFP bilirubin, ALP Karnofsky BCLC* Number of nodules, size, vascular invasion Child, portal hypertension Performance status treatment allocation CUPI* TNM, AFP bilirubin, ALP, ascites symptoms JIS* TNM Child - * External validation

9 Current guidelines: BCLC

10 BCLC and prognosis Marrero J, Hepatology 2005

11 BCLC management and staging system EASL EORTC Clinical Guidelines on the Management of HCC. 2012

12 Radiological criteria for treatment decision -Size -Number -Localization sub capsular, peri vascular 1 or >1 hepatic segment uni or bilobar -Macroscopic vascular invasion -Biliary invasion

13 Size, number and recurrence UCSF: 1 nodule 6.5cm or up to 3 4.5cm each (max sum of the Ø 8cm) Milan: 1 nodule 5cm or up to 3 3cm each Decaens T, Liv Transplant 2006

14 Size, number and recurrence Decaens T, Liv Transplant 2006

15 Eligibility criteria for liver transplantation «Liver transplantation is considered to be the first-line treatment option for patients with single tumors 5 cm or 3 nodules 3 cm (Milan criteria). Modest expansion of Milan criteria in patients without microvascular invasion achieves competitive outcomes, and requires prospective validation.» EASL EORTC Clinical Guidelines on the Management of HCC. 2012

16 Eligibility criteria for liver transplantation Rate of patients (%) transplanted outside Milan criteria (UNOS). Toso C, Hepatology 2009

17 Criteria for LT and outcome Mazzaferro V. Liv Transplant 2007 Mazzaferro V. Ann Surg Oncol. 2008

18 Eligibility criteria for LT: Total Tumor Volume TTV= sum of the volume of each tumor (4/3)π r 3 (r=maximal radius of each HCC) TTV 115 cm3 Radiology-based staging: cumulative survival and cumulative risk of HCC recurrence. Toso C, Liver Transpl 2008

19 Eligibility criteria for LT: TTV and AFP Toso C, Hepatology 2009

20 Management after treatment Importance of the evaluation of the response to treatment (ARTERIAL enhancement). -Complete response -Partial response -Stable disease -Progressive disease

21 Contribution of the radiologist - Diagnose HCC by noninvasive criteria. - In case of an atypical lesion: propose another imaging modality, biopsy or follow-up according to the guidelines. - Describe potential contraindications to treatment: portal vein thrombosis, ascites, portal hypertension, extra hepatic metastasis The radiologist is intimately involved in the treatment decisions (multidisciplinary team+++)

22 Take home messages 1. Discuss the HCC management guidelines. -BCLC management guidelines endorsed by AASLD and EASL. 2. Recognize the hierarchy of treatment in the BCLC staging system. -Favor curative treatment -Surgical: resection - transplantation Locoablative: RFA > TACE 3. Identify the role of the radiologist in the clinical management of HCC. -Diagnose HCC by noninvasive criteria -Manage atypical lesions -Identify potential contraindications to treatment