Liver and Biliary Tract-Tumors

Liver and Biliary Tract-Tumors
Presentation lecture by:Inga Gurevich, MD, PhD

Liver - Benign Tumors and Tumor Like Conditions

* Focal nodular hyperplasia
* Liver cell adenoma
* Hemangioma (most common benign lesion)
* Mesenchymal hamartoma

Focal nodular hyperplasia (FNH)
* Common (#2 liver tumor after hemangioma)
* Mass lesion of young (median age 38 years); some studies show female predominance
* Represents 2-10% of pediatric hepatic tumors
* May be associated with oral contraceptives (66-95% of cases), hepatic cavernous hemangioma (20%), glycogen storage disease type Ia, portal hypertension
* Tumors associated with oral contraceptives often have hemorrhage, necrosis, infarction
* Usually an incidental finding; present in 1% of autopsies
* Xray: mass with central scar, centrifugal hypervascularity by angiography; CT and MRI are important,
* Treatment: excellent prognosis; discontinue oral contraceptives, if applicable; surgery if symptomatic, complications, compression of adjacent organs or lesion progression
* Well-demarcated, subcapsular, light brown to yellow ; bulging nodule, 70-80% solitary, up to 5 -10cm; has central gray-white stellate scar (unless < 1 cm) from which fibrous septa radiate to periphery and create multiple smaller nodules; hemorrhage, necrosis, infarction, bile staining often seen; larger tumors may have multiple scars; adjacent liver is normal
* Micro: Most tumors (80%) have the 3 classic features of abnormal architecture, bile ductular proliferation and malformed vessels.
* Non-classic forms lack either abnormal architecture or malformed vessels, and are divided into three types - (a) telangiectatic, (b) mixed hyperplastic and adenomatous or (c) atypia of large cell
* Positive stains: alpha-1-antitrypsin
* Negative stains: p53, CD143 (angiotensin I-converting enzyme: reduced expression
* DD: Osler-Weber-Rendu disease, Budd-Chiari syndrome or cirrhosis (adjacent liver is not normal), fibrolamellar hepatocellular carcinoma (marked atypia of hepatocytes), hepatocellular adenoma (encapsulated, monoclonal)

Liver Cell Adenoma
Hemangioma
Mesenchymal Hamartoma
Liver Cell Tumors - Malignant
* Hepatocellular carcinoma
* Hepatoblastoma
* Epithelioid hemangioendothelioma
* Angiosarcoma
* Undifferentiated (embryonal) sarcoma
* Squamous Cell Carcinoma
* Carcinoid Tumor
* Lymphoma/leukemia

Hepatocellular carcinoma
Clear cell variant of hepatocellular carcinoma
Fibrolamellar Variant of Hepatocellular Carcinoma
Hepatoblastoma
Epithelioid Hemangioendothelioma
Angiosarcoma
Undifferentiated Sarcoma
Bile Duct Tumors
Bile Duct Adenoma
Biliary Cystadenoma
Biliary Cystadenocarcinoma
Cholangiocarcinoma (intrahepatic)
case studies ..

Liver and Biliary Tract-Tumors.ppt

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Treatment for Chronic Hepatitis B

Treatment for Chronic Hepatitis B
Screening for Hepatocellular Carcinoma
Presentation by:Mindie H. Nguyen, MD, MAS
Assistant Professor of Medicine
Division of Gastroenterology & Hepatology
Stanford University Medical Center

Chronic Hepatitis B
HBV Disease Burden in Asian-Americans
Hepatitis B Prevalence
Etiology of HCC in Asians
Impact of HBV DNA and ALT Levels on Disease Outcomes
Disease Progression and HCC Risk
Impact of Viral Load
* High viral load:
* Reduction in viral load:
HBV DNA Associated with Increased Risk of HCC
HBV DNA levels and Risk of Cirrhosis and HCC REVEAL-HBV Study
HBV DNA Levels Predict Risk of Developing Cirrhosis
Viral Load Is the Main Predictor of Cirrhosis Regardless of Serum ALT
HBV DNA Levels Predict Risk of Developing HCC
Dose-Response Relationship:
HBV DNA and HCC
HBV DNA Levels are Associated With Clinical Outcomes (HCC)
REVEAL-HBV Study: Cirrhosis Analysis Conclusions
REVEAL-HBV Study: HCC Analysis Conclusions
Impact of Treatment on Disease Progression
Primary Goal of Treatment
Rapid and sustained suppression of HBV to the lowest possible level1,2 Outcomes
Rapid and Profound HBV Suppression: an Important Therapeutic Goal
Lamivudine and Disease Progression and HCC incidence in Advanced HBV (stage III/IV)
HBV DNA Suppression Reduces Cirrhosis Progression
Lamivudine
Placebo
Diagnosis of HCC
HBV DNA Suppression Reduces HCC Incidence Rate
Conclusions
Summary

* HBV DNA is an essential marker for predicting risk for complications
* Viral suppression is associated with improved treatment outcomes in patients with advanced fibrosis.
* Emerging potent antiviral therapies provide the potential for more effective treatment response and prevention of complications of CHB

Screening for Hepatocellular Carcinoma
Screening for HCC Consensus Recommendations
HCC: Screening Tests
Changes in sensitivity and specificity of AFP for diagnosis of HCC using various cut-offs
WHO Principles of Screening
Screening improves survival
HCC Screening: clinical studies
Pseudo-Disease
RCT for HCC Screening
Cost-Effectiveness of Screening: Other Cancers
Cost-Effectiveness of HCC Screening
Real-life studies with cost information:
Screening for HCC: Summary

Treatment for Chronic Hepatitis B.ppt

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Hepatocellular Carcinoma: Screening, Diagnosis, and Treatment

Hepatocellular Carcinoma: Screening, Diagnosis, and Treatment
Presentation lecture by: Catherine Frenette, MD
California Pacific Medical Center
The Barry S. Levin Department of Transplantation


Hepatocellular Carcinoma
Increasing prevalence of patients with cirrhosis
Regional Variations in HCC-related Mortality
Risk Factors for HCC
Chronic Hepatitis
Cirrhosis
HCC
Chronic HBV Infection
Inactive Carrier State
Chronic Hepatitis
Clinical Outcome of Chronic Hepatitis B
HCC Epidemiology
HBV DNA Associated with Increased Risk of HCC
Primary Prevention of HCC
Surveillance Recommendations
Surveillance for HCC Prolongs Survival
Cost-Effectiveness of HCC Surveillance
Quad Phase Imaging of Hepatocellular Carcinoma
Liver transplantation
Curative treatments
Randomized controlled trials
HCC: Barcelona Clinic Liver Cancer
Staging Classification
Factors Determining Prognosis of Hepatocellular Cancer
Management of Hepatocellular Carcinoma
Newer modalities
Surgical Resection: Indications
Liver Transplantation
UNOS Criteria for Liver Transplantation for HCC
Liver Transplantation for HCC
Months After Transplantation Patients at Risk
Liver Transplantation for HCC: Outcomes Applying Milan Criteria
Liver Transplantation for HCC UCSF Criteria
Differentiated histology
Local Ablation Therapy for Transplant Candidates
Trans-Arterial Chemoembolization TACE
Catheter-Based Therapies
TACE for HCC
Radiofrequency Ablation
RFA Modalities
RFA Indications
RFA Contraindications
RFA Complications
Radiographic Outcomes
New Therapies Under Investigation
Chemotherapy

* Sorafenib* (Nexavar)
* Erlotinib (Tarceva)
* Sirolimus (Rapamune)
* Capecitabine (Xeloda)
* Floxuridine (FUDR)
* Bevacizumab (Avastin)
* Sargramostim (Leukine)
* Oxaliplatin (Eloxatin)
* Imatinib (Gleevac)
Local Therapy
Yttrium-90 Microspheres
Doxorubicin Eluting Beads
Systemic chemotherapy
GI Intergroup Recommendations
Macrovascular invasion or Metastases
Supportive Care
Conclusion

* Screening saves lives
* Resection or Transplantation best option
* RFA used for unifocal lesions < 5 cm
* TACE used for multifocal, lesions > 5 cm
o Non surgical candidates
* Combination therapies
o TACE and RFA
* New Strategies
o Yttrium-90 theraspheres
o Drug Eluting microspheres
* Sorafenib used when local treatment not an option


Hepatocellular Carcinoma: Screening, Diagnosis, and Treatment.ppt

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