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Flashcards in Liver Cancer Deck (32):
1

What is the indo-cyanine green test?

Correlates with MELD score.
RR of mortality for major hepatectomy increase 3x if ICG retention at 15 minutes >14%

2

What is the adequate future liver remnant percentage?

Normal liver: FLR of at least 25% to prevent postop liver failure
Cirrhotic liver: FLR up to at least 40% necessary

Inadequate FLR is the most common factor precluding curative LR

3

What is the Milan Criteria?

1) Single lesion, 5cm or less
2) No more than 3 nodules, each

4

Which is better in early HCC?
Liver Resection or Liver Transplant.
Why

Liver Transplant
- Better survival with liver transplant if HCC within Milan criteria
- Lower recurrence rate, but poorer long-term outcome

5

What is the 5-yr OS in liver transplant for HCC?

N=4500
Pelletier 2009

5yr OS within Milan 65%
5yr OS outside Milan 40%

6

Describe RFA

1) Most efficacious for small volume HCC (No more than 3 lesions, each no more than 3cm)
2) 5yr OS 30-60%
3) risk of Mortality 1%, Complx risk 3-7%
4) No diff in OS & DFS compared to resection. Less Complx with RFA
5) RFA superior to PEI in RR, OS, RFS

7

Describe TACE

TACE = Trans-arterial Chemoembolisation
1st line Tx for unrest table, large/multi focal HCC w/o vascular invasion/etrahepatic spread

Can be used prior to resection/bridging therapy prior to transplant

Doxorubicin/CDDP

CR 2%, Disease control rate 40%.

ORR 20-60%

8

What is the post-embolization syndrome?

~90% following TACE.
Fever, malaise, RUQ pain, nausea+vomiting

9

Contra-indications to TACE

Absolute:
- Thrombus in main portal vein and portal vein obstruction (high risk of liver failure)
- Encephalopathy
- Biliary Obstruction
- CP score C

Relative:
- BIL >34
- LDH >425
- AST >100
- Tumor burden >50% of liver
- Cardiac/renal insufficiency
- Ascites, recent variceal bleed, significant thrombocytopenia
- Transjugular inhtrahepatic portosystmic shunt (TIPS)

10

Conventional TACE vs DCBeads TACE

PRECISION V Trial
- Phase II, n=200
- TACE (Doxorubicin) vs DC Beads (Doxorubicin)
- non-significant results. Trend towards improved RR and disease control rate
- Significant: Less liver toxicity, less Doxorubicin toxicity with DC beads

11

What is the role of combining Sorafenib + TACE in intermediate HCC?

SPACE (Sorafenib or Placebo in combination with TACE in HCC)

Phase II, RCT, 2 arms:
- DC TACE + SORAFENIB
- DC TACE + Placebo

Incl criteria:
- unrest table HCC

12

Role of Chemoimmunotherapy in HCC
- using PIAF regimen

PIAF = CDDP, Doxorubicin, IFNa, CI 5FU
- Phase III compared PIAF to doxorubicin.
- n=200
- RR 20% vs 10%, not significant. No CRs
- Med Survival 8.7m vs 7m
- Sig more toxicities: 80% neutropenia, 60% thrombocytopenia

13

What is the EACH study?

Phase III, RCT, n=370. 2 arms:
- FOLFOX4 vs Doxorubicin group

14

Role of XELOX in HCC?

Phase II study, n=50
ORR 6%, DCR 70%
Med OS 9.3m

15

Describe the SHARP trial

Llovet NEJM 2008
N=300

Advanced HCC, CPA, ECOG 0-2, Life expectancy at least 12 months
Randomized to Sorafenib vs Placebo

RR 2%vs 1%
TTP 5.5 m vs 3m
0S 10.7m vs 8

16

Describe the Asia-Pacific study

Advanced HCC, ECOG 0-2, CP A
2 groups: Sorafenib vs placebo
-N=226

RR 3% vs 1%
TTP: 3m vs 1.5 m
OS 6.5m vs 4m

17

Side-effects of Sorafenib

Diarrhea
HFS
Fatigue
Rash

18

Any Role for Adjuvant Therapy in HCC?

No!
STORM trial was negative.
N=1100
Sorafenib as adjuvant tx in prevention of Recurrence of HCC

Prior tx of:
-Resection
-RFA
-PEI

19

In Whom is HCC Screening & Surveillance is Recommended?

1) Hepatitis B Carriers (HBsAg +)
- Asian males >40yo; Females >50yo
- All cirrhotic Hep B carriers
- FHx of HCC
- Africans >20yo
2) Non-Hep B Cirrhosis
- Hep C
- Alcoholic Cirrhosis
- Genetic hemochromatosis
- Primary Biliary Cirrhosis
- possibly: AAT deficiency, NASH, Autoimmune hepatitis

20

Name some Staging systems for HCC

1) Okuda Staging
2) Child-Turcotte-Pugh (for cirrhosis)
3) BCLC staging
4) CLIP staging (Cancer of the Liver Italian Program)
5) CUPI

21

Describe the Okuda Staging

Uses Tumor size, presence of Ascites, Bilirubin and serum Albumin

Stage I: No + factors
Stage II: 1-2 positive factors
stage III: 3-4 positive factors

22

Describe the CLIP Staging.
- Cancer of the Liver Italian Program

1) Components:
- Child-Pugh Score,
- Tumor morphology and % of involvement of liver
- AFP
- Portal Vein thrombosis

Does not adequately assess those undergoing radical therapies (eg. Resection/transplantation)

23

Describe HBV cancer-promoting actions:

1) Insertional mutagenesis
2) p3 inhibition
- explains why it can induce HCC in non-cirrhotic liver

24

What are the variables that affect risk of recurrence following resection of HCC?

1) Tumor size
2) Number of tumors
3) Vascular invasion
4) Width of resection margin

25

What are the methods of Percutaneous Ablation for HCC?

1) Percutaneous Ethanol Injectino
2) RFA
3) Injection of acetic acid
4) Injection of boiling saline
5) Cryotherapy
6) Microwave therapy
7) Laser therapy

26

Usage of TACE is limited to what group of patients?

Preserved liver function
Absence of extra hepatic spread
Absence of vascular invasion
No significant cancer-related symptoms

TACE may offer palliative benefits for patients with intermediate stage HCC, with 5-yr survival rates > 50%

27

Explain TACE

TACE = Transarterial Chemoembolization

Induce ischemic tumor necrosis via acute arterial occlusion

Emboli station may be done alone (Transarterial embolization) or combined with selective intraarterial chemotherapy (TACE)

28

What are the factors in the CUPI score?

CUPI = Chinese University Prognostic score
(A.A.A.A.T.T)

Variables include:
1) TNM stage
2) Asymptomatic disease on presentation
3) Ascites
4) AFP
5) Total bilirubin
6) ALP

29

What are the factors in Okuda staging

1) Tumor Size
2) Ascites
3) Albumin
4) Bilirubin

30

What are the risk factors for HCC?

Hep B, C
Alcohol
Genetic hemochromatosis
NASH
Stage 4 primary biliary cirrhosis
Alpha1-anti trypsin deficiency
Other causes of cirrhosis

31

What are the risk factors for HCC?

Hep B, C
Alcohol
Genetic hemochromatosis
NASH
Stage 4 primary biliary cirrhosis
Alpha1-anti trypsin deficiency
Other causes of cirrhosis

32

What are the risk factors for HCC?

Hep B, C
Alcohol
Genetic hemochromatosis
NASH
Stage 4 primary biliary cirrhosis
Alpha1-anti trypsin deficiency
Other causes of cirrhosis