Hepatocellular

Question 1

Epidemiology -4

Answer 1

Males > Female (2.9:1),

mean age ~50-60,

rare but rising in US due to Hep C,

higher incidence in China, Africa, Asia

Question 2

Risk Factors -9

Answer 2

HBV, 
HCV, 
cirrhosis, 
anabolic steroids, 
hereditary hemochromatosis, 
aflatoxin chemical that contaminates corn, soybeans, peanuts in China, Africa (high incidence of HCC in these), 
nitrosamines, 
vinyl chloride, 
arsenic

Question 3

Prevention -2

Answer 3

HBV (vax),

HCV (dec blood transfusions, needles, unprotected sex)

Question 4

Screening -2

Answer 4

Screen pts at high risk of HBV, HCV, and cirrhosis.

alpha-fetoprotein (AFP) levels in clinical trials.

Question 5

Signs and Symptoms -7

Answer 5

hepatic mass (need to r/o different primary cancer or benign dz),

R upper abd pain,

wt loss (anorexia, early satiety),

obstructive jaundice,

sudden LFT inc,

sudden ascites (rapid loss of hepatic function),

tumor fever

Question 6

Diagnosis

Answer 6

AFP, LFTs, PT, PTT, HBV, HCV, spiral CT, MRI with contrast to confirm

bx rarely needed and should avoid to decrease possible tumor seeding prior to resection

Question 7

Prognostic Factors -3

Answer 7

OS unresected 3-4mo.

resected 5-yr DFS 5% with recurrence rates 70-100%.

AFP, PS, ascites (liver function), mets most common to bone and lung but pts die most often of liver failure

Question 8

Treatment Options SURGERY -3

Answer 8

surg is std of care.

5 yr OS 30-40% if among 30% pts who qualify for surg. median OS ~3yr.

cirrhosis pts do poorly (transplant an option in some if can get liver in <6mo IF RESECTED).

Question 9

locoregional therapy -5

Answer 9

1. TACE: doxorubicin, ciplatin, or mitomycin c.
2. Hepatic arterial chemo -5FU or fluorodeoxyuridine (FUDR) +/- cis or doxo.
3. Percutaneous ethanol inj
4. radiofrequency ablation
5. cryosurg

Question 10

radiation -2

Answer 10

palliative only, commonly as chemoXRT

liver can not tolerate much XRT

Question 11

treatment by stage - chemo - advanced dz -3

WHAT IS SOC?

FYI NO SOC FOR 2nd line

Answer 11

no std of care,

RR <20%, median OS 4-9 mo

doxo, 5FU, FUDR, mitomycin c, PIAF (cisplatin, interferon, doxorubicin, 5FU), gem, thalid, gem/cis, doxo/cis, gem/oxal, gex/oxal/bev

Question 12

SHARP trial - targeted therapy - metastatic -4

Answer 12

sorafenib 400mg PO bid is SOC (cat 1).

Use for unresectable or mets

med OS 11.5 vs 8.5 mo with placebo

TTP 6 vs 3 mo.

First systemic tx to prolong survival.

Question 13

immune therapy -2

Answer 13

interferon used in HCV pts

both chemopreventative and adj tx after tumor ablation

Question 14

treatment by stage - localized resectable dz. -2

Answer 14

SURGERY IS SOC

adj chemo or adj chemoembo is investigational STUDY

Question 15

treatment by stage - localized or locally advance unresectable dz -5

Answer 15

• no real std of care
• locoregional tx (if tumor <5cm)
• targeted tx (sorafenib std if not transplant candidate)
• chemo no OS benefit

Question 16

sorafenib ADR -5

25% of pts stopped tx due to ADR

Answer 16

diarrhea

HFS

rash or desquamation

anorexia

alopecia

Question 17

Surgery candidate

Answer 17

Nothing beyond cirrhosis child pughs A
<=3 tumors
No extrahepatic