mesenteric angiography power injections times for 1. proximal anatomical delineation 2. parenchymal background 3. venous outflow

1. 0-2 seconds 2. 2-10 seconds 3. 10-20 seconds

Y90 HCC Flashcards by George Athanasatos

Why is complete pathological necrosis important for HCC Y90

tumors with CPN had lower HCC recurrence rate than tumors with incomplete necrosis
CPN has lower HCC-related mortality, recurrence free survival, and longer time to recurrence

https://pubmed.ncbi.nlm.nih.gov/32749512/

How well did you know this?

Not at all

Perfectly

Target dose per LEGACY trial for HCC segmental Y90 infusion

> 400 Gy

How well did you know this?

Not at all

Perfectly

how many segments are in a radiation segmentectomy

2 segments or less

How well did you know this?

Not at all

Perfectly

check list of vessels to watch for in MAA mapping

GDA
cystic
Right gastric artery
gastrohepatic trunk
falciform

How well did you know this?

Not at all

Perfectly

characteristic appearance of the cystic artery

inverted Y or “forked tongue” appearance

How well did you know this?

Not at all

Perfectly

mesenteric angiography power injections times for

proximal anatomical delineation
parenchymal background
venous outflow

0-2 seconds
2-10 seconds
10-20 seconds

How well did you know this?

Not at all

Perfectly

tumor size and liver volume percentage radiation major hepatectomy is performed

Patients with HCC 5 cm or larger, greater than 60% of the total liver volume

https://learn.sirweb.org/pluginfile.php/61503/block_html/content/Feb%202024%20JVIR%20article.pdf

How well did you know this?

Not at all

Perfectly

what is the Future liver remnant per Nontumor liver volume radiation major hepatectomy be performed

FLR/NTLV has to be greater than 30%

https://learn.sirweb.org/pluginfile.php/61503/block_html/content/Feb%202024%20JVIR%20article.pdf

How well did you know this?

Not at all

Perfectly

according to the IFU for theraspheres, what is the maximum dose that is recommended to the total liver volume

150Gy per whole liver

How well did you know this?

Not at all

Perfectly

what is the standard definition of major hepatectomy

resection of 4 or more liver segments

How well did you know this?

Not at all

Perfectly

other than a FLR/NTLV of greater than 30%, what other criteria were listed for performing radiation major hepatectomy

Child-Pugh Class A
ECOG 0
no vascular invasion
less than 5 tumors
no evidence of extrahepatic spread
no tumor in the FLR
estimated lung dose <30Gy while achieving >150Gy in the perfused volume

https://learn.sirweb.org/pluginfile.php/61503/block_html/content/Feb%202024%20JVIR%20article.pdf

How well did you know this?

Not at all

Perfectly

lung dose threshold has to be less than what

less than 30 Gy

How well did you know this?

Not at all

Perfectly

Epidemiology of liver cancer - how common is it worldwide and where does it rank in cancer-related deaths?

6th most common cancer worldwide
3rd leading cause of cancer related deaths world wide and in the US

How well did you know this?

Not at all

Perfectly

what is the strongest risk factor for developing HCC

cirrhosis

How well did you know this?

Not at all

Perfectly

what is the annual risk of developing HCC in patients with cirrhosis

around 2 %

How well did you know this?

Not at all

Perfectly

what is the leading cause of HCC in the absence of cirrhosis

NAFLD - approximately 1/4 to 1/3 of NAFLD-related HCC occurs in the absence of cirrhosis

How well did you know this?

Not at all

Perfectly

what beverage may be recommended for patients with chronic liver disease

Coffee (but with no additives)
At least one cup of coffee consumption is dose-dependently assocated with a significant reduction in HCC risk

How well did you know this?

Not at all

Perfectly

what medications have a protective effect against HCC

aspirin (43-60% reduction in HCC risk with aspirin use exceeding 5 years)
statins (potential benefit from lipophilic statins but not hydrophilic statins)
metformin (conflicting data)

https://journals.lww.com/hep/fulltext/2023/12000/aasld_practice_guidance_on_prevention,_diagnosis,.27.aspx

How well did you know this?

Not at all

Perfectly

should statins be avoided in patients with chronic liver disease

How well did you know this?

Not at all

Perfectly

does HCC surveillance have any benefit in patients with Child-Turcotte-Pugh score C

No, unless they are a transplant candidate

How well did you know this?

Not at all

Perfectly

what is the difference between MASH and NAFLD

MASH is a more severe form of NAFLD. It includes all the features of NAFLD but with additional inflammation and liver cell injury.

MASH has a higher risk of progressing to advanced liver diseases compared to simple NAFLD.

How well did you know this?

Not at all

Perfectly

What stage of fibrosis is considered cirrhosis

Stage 4

Stages of Liver Fibrosis
F0: No fibrosis.
F1: Mild fibrosis with portal expansion.
F2: Moderate fibrosis with more extensive portal expansion and some bridging fibrosis.
F3: Severe fibrosis with bridging fibrosis but no cirrhosis.
F4: Cirrhosis. This stage is characterized by extensive fibrosis with the formation of regenerative nodules and significant disruption of liver architecture

How well did you know this?

Not at all

Perfectly

what surveillance test(s) do the AASLD recommend

Study These Flashcards

combo of US and AFP
https://journals.lww.com/hep/fulltext/2023/12000/aasld_practice_guidance_on_prevention,_diagnosis,.27.aspx

GALAD panel sensitivity range for early HCC detection

Study These Flashcards

60-80% sensitivity
82% specificity

Berhane S, Toyoda H, Tada T, Kumada T, Kagebayashi C, Satomura S, et al. Role of the GALAD and BALAD-2 Serologic Models in Diagnosis of Hepatocellular Carcinoma and Prediction of Survival in Patients. Clin Gastroenterol Hepatol. 2016;14:875–886 e876.

Marrero JA, Marsh TL, Parikh ND, Roberts LR, Schwartz ME, Nguyen MH, et al. GALAD score improves early detection of HCC prior to the diagnosis of HCC: A phase 3 biomarker validation study. Abstract #138. Hepatology. 2021;74:92A.

GALAD panel composition

gender, age, AFP-L3, AFP, DCP

how often should HCC surveillance be performed

every 6 months *this recommendation was initially based on HCC tumor doubling time

AFP 20 ng/mL sensitivity and specificity

sensitivity around 60% specificity around 90%

AASLD next step if screening US for HCC shows a subcentimeter lesion

Repeat US and AFP in 3-6 months

AASLD next step if screening US for HCC shows a 1 cm or greater lesion

further imaging with multiphasic CT or MRI

percentage of HCC that can have normal AFP levels

over 40% Arif D, Mettler T, Adeyi OA. Mimics of hepatocellular carcinoma: a review and an approach to avoiding histopathological diagnostic missteps. Hum Pathol. 2021;112:116–27

other tumors that may have elevated AFP levels

intrahepatic cholangiocarcinoma, gastric cancer, and germ cell tumors

is the diagnosis of HCC based on elevated AFP alone valid

no - need imaging or biopsy if imaging non-characteristic

who does LI-RADS not apply to

patients without cirrhosis or at-risk chronic HBV infection

when is a CT chest recommended for patients with HCC

when tumor is 2 cm or greater in size to assess for lung mets *all patients beyond stage 0 of the BCLC criteria

when is staging with CT pelvis and Technetium-99m Bone scan recommended for HCC

1. patients with AFP greater than 1000 ng/mL 2. macrovascular invasion 3. multifocal bilobar disease

factors to consider for surgical resection of HCC

1. tumor number 2. anatomic location 3. presence of vascular invasion 4. anticipated FLR 5. liver function 6. presence of clinically significant portal hypertension

FLR needed with cirrhosis vs. without

40% with cirrhosis 30% without cirrhosis

how is clinically significant portal hypertension defined

HVPG greater than 10

what are surrogates for CSPH when not using HVPG

presence of ascites and varices, and platelet count <100k

risk of HCC recurrence following surgical resection

50-70% at 5 years

high risk features for HCC resection patients

1. tumor size greater than 5 cm 2. more than 3 tumors 3. micro/macrovascular invasion 4. poor tumor differentiation

what is the recommended treatment for localized HCC in the absence of underlying cirrhosis

surgical resection

when should surgical resection be considered in patients with cirrhosis

when there is 1. limited tumor burden 2. well-compensated cirrhosis 3. no CSPH 4. adequate FLR

what type of therapy is recommended for post-resection HCC patient with high risk of recurrence

adjuvant treatment with atezo and Bev (IMbrave 050)

HCC recurrence rate after transplantation vs. resection

transplantation: 10% resection: 50-60% AASLD paper: file:///C:/Users/George/Downloads/aasld_practice_guidance_on_prevention,_diagnosis,.27%20(2).pdf

what is the criteria for HCC transplant known as

the Milan criteria

what is used to rank liver transplant candidates

MELD-Na

what type of immune checkpoint inhibitors are there for HCC treatment

1. anti-PD-1 2. anti-PD-L1

what are the Anti-PD-1 immune checkpoint inhibitors

nivolumab (Opdivo) and pembrolizumab (Keytruda)

what are the anti-PD-L1 immune checkpoint inhibitors

Atezolizumab (Tecentriq) Avelumab (Bavencio) Durvalumab (Imfinzi)

What risk to immune check point inhibitors carry in cases for potential liver transplant

Immune checkpoint inhibitors (ICIs) may increase risk of rejection and graft loss,

If a patient was on an immune checkpoint inhibitor for liver transplant bridging, how long should they be off of them prior to transplant

If patients receive ICIs prior to LT, we recommend discontinuation of these agents at least 3 months prior to LT - per AASLD guidelines

recurrence rate of HCC post liver transplant

Even with adherence to the Milan criteria, HCC recurs post-LT in 10%–15%

the two most common sites for post liver transplant HCC recurrence

the lung (40%) and the liver (33%)

HCC ablation has a similar survival for tumors of what size

2 cm or less

what did the IMbrave 050 study results demonstrate

IMbrave 050 phase III RCT demonstrated superior recurrence-free survival using atezolizumab plus bevacizumab in the adjuvant setting for HCC patients at high-risk of recurrence after surgical resection or local ablation. High-risk features for patients undergoing ablation in this trial included tumor size >2 cm but ≤5 cm and multifocal HCC.

Y90 HCC Flashcards

(56 cards)