LIVER TUMOUR

OLEH :
Dr.HANS MARPAUNG, SpB,FICS

ANATOMY
The liver weighs 15002000 g and so is the largest gland in
the human body.
Traditionally, the insertion into the liver of the falciform
ligament was thought to divide the liver into a right and a
left lobe.
In 1981, Couinaud provided a more accurate
description of the segmental anatomy of the liver
The true division into a right and a left lobe lies in
the main lobar fissure, an oblique plane passing from the
gallbladder fossa anteriorly to the bed of the inferior vena
cava posteriorly (Cantiles line).

Structure

Tumours in the liver can be benign or

malignant.
Malignant tumours can be primary or,
more commonly, secondary ( metastatic).

MALIGNANT PRIMARY LIVER NEOPLASMS

The most common malignant primary tumors are
Hepatocellular Carcinoma (HCC) or Hepatoma and
Cholangiocarcinoma.
HCC arises from the hepatocytes and cholangiocarcinoma
from the epithelium of the intrahepatic biliary tract.
The tumor, referred to as Hepatoblastoma,
occurs almost exclusively in the first 3 years of life.

HEPATOCELLULAR CA Epidemiology
One of the most common tumors in the world & 3rd
mortality
Usually arise in the setting of chronic viral hepatitis
or cirrhosis secondary to other causes
Earlier peak incidence in Asia and Africa than in
Western countries(1~2 decades)
More common in men than in women ( 4:1)

The Global Perspective

The Big Five Cancers

Liver
13 %

Lung
2 7%

C o lo rect al
20%

B reast
20%

St o mach
20%

The Major Etiological Factors

Chronic hepatitis - types B or C
Cirrhosis/chronic liver disease of
any type
Aflatoxin exposure
Males, increasing age

Cirrhosis
Immature, non-functional cells

Major Risk Factors

HBV

5-15 fold increased risk

70-90% of cases occur in setting of

cirrhosis

Treatment does NOT decrease risk

Risk highest in carriers and lower in

immune
HCV

1-3% of cirrhotic patients develop

HCC

Treatment seems to decrease risk

Co-infection
Aflatoxins (Aspergillus fumigatus)

4 fold increased risk HCC

Alcohol

>50-70g/day

No link to direct carcinogenic effect

Synergistic with HCV and HBV

Nonalcoholic Steatohepatitis?
El-Serag, H.B. and K.L. Rudolph, Hepatocellular carcinoma: epidemiology and molecular carcinogenesis. Gastroenterology, 2007. 132(7): p. 2557-76.
Brunetto M.R., O.F., Koehler M., et al., Effect of interferon-alpha on progression of cirrhosis to hepatocellular carcinoma: a retrospective cohort study.
International Interferon-alpha Hepatocellular Carcinoma Study Group. Lancet, 1998. 351(9115): p. 1535-9.

Chronic HBV Infection

Geographic Distribution

8% - High
2-7% - Intermediate
<2% - Low

Data from CDC

Clinical Staging
Numerous staging systems exist and NO
CONSCENSUS

E.g. TNM, Okuda, CLIP, and BCLC

Incorporate 4 determinants of survival

Severity of underlying liver disease

Size of tumor
Extension of the tumor into adjacent structures
Presence of metastases

Primary staging should be clinical staging

Secondary staging with the AJCC TNM

Child-Pugh classification
Criteria

Total Serum Bilirubin

Bilirubin <2 mg/dl: 1 point

Bilirubin 2-3 mg/dl: 2 points
Bilirubin >3 mg/dl: 3 points

Serum Albumin

INR

Albumin >3.5 g/dl: 1 point

Albumin 2.8 to 3.5 g/dl: 2 point
Albumin <2.8 g/dl: 3 point
INR <1.70: 1 point
INR 1.71 to 2.20: 2 point
INR >2.20: 3 point

Ascites

No Ascites: 1 point
controlled mdically: 2 point
poorly controlled: 3 point

Encephalopathy

No Encephalopathy: 1 point
medically controlled : 2 point
poorly controlled: 3 point

Interpretation
Child Class A: 5 to 6 points

Life expectancy: 15 to 20 years

Abdominal surgery peri-operative
mortality: 10%

Child Class B: 7 to 9 points

Indicated for liver transplantation

evaluation
Abdominal surgery peri-operative
mortality: 30%

Child Class C: 10 to 15 points

Life expectancy: 1 to 3 years

Abdominal surgery peri-operative
mortality: 82%

Okuda stage
Tumor size (< or > 50% of the liver)
Ascites (absent or present)
Bilirubin (< or > 3)
Albumin (< or >3)

Natural history without treatment

Stage (0 pt) : 8 months
Stage (1-2 pt) : 2 months
Stage (3-4 pt) : less than 1 month

CLIP Score

Child-Pugh
A

Tumor morphology
Uninodular and extension 50%

Multinodular and extension 50%

Massive or extension >50%

AFP
<400

>400

Portal Vein Thrombosis

No

Yes

Prospective validation of the CLIP score: A new prognostic system for patients with cirrhosis and hepatocellular carcinoma. Hepatology 2000; 31:840

TNM - AJCC
Stage I

T1

N0

M0

55% 5 yr survival

Stage II

T2

N0

M0

37% 5 yr survival

Stage IIIA

T3

N0

M0

16% 5 yr survival

IIIB
IIIC
Stage IV

T4
Any T
Any T

N0
N1
Any N

M0
M0
M1

T definitions
T1 solitary nodule without vascular invasion
T2 solitary tumor with vascular invasion or multiple nodules all <5cm
T3 multinodular >5cm, or tumor with major vasculature invasion
T4 Tumor with invasion of adjacent organs
AJCC Cancer Staging Manual, Sixth Edition (2002) published by Springer-Verlag New York, Inc

Tumor Detection
Initially, hard to detect
To screen high-risk patients periodically
* Infectious hepatitis or family history of HCC
Surveillance tools for HCC
* AFP blood test & ultrasound examination
Symptoms
* Painless mass in right hypochondriac region.
* Liver is hard, irregular and often massively enlarged
* Weight loss, fever, nausea, weakness, tenderness,
jaundice.
* Ascites (40%) often it is massive, splenomegaly and
features of portal hypertension may be present.

Diagnosis
Detection of mass in cirrhotic liver is highly suspicious
for hepatocellular carcinoma.
Diagnostic strategies are dependent on diameter
sizes.
>2 cm in diameter, 1-2 cm in diameter and <1 cm in
diameter
Lesions <1 cm diameter have low likelihood of being
malignant, but should still be followed-up. Lack of
growth over 1-2 years suggests it is not HCC.
https://www.aasld.org/
Nakshima T, et al. Hepatocellular Carcinoma. Tokyo: Springer Verlag,
1987

Spread of Tumour
Lymphatic spread: it can spread to other part of liver

through lymphatic within the liver, to the lymph nodes

in the porta hepatis and other abdominal lymph nodes
later. Often spread occurs directly to cisterna chyli.

Blood spread: To lung, bones and adrenals often can

occur.

Direct infiltration: To diaphragma and neighbouring

structures.

Diagnosis

https://www.aasld.org/

Tumour Detection

Evaluation
Prognosis depends on 2 separate factors
-Tumor : size, number, vascular invasion, extrahepatic disease
-Liver disease : Child-Pugh,Perfomance status
Lesion imaging, lab results, patients age, overall health
(underlying cirrhosis, involvement of both hepatic lobes,
distant metastasis lung, brain, bone , adrenal gland)
Imaging procedure
: Ultrasound, CT, Hepatic angiography, MRI, PET

BCLC (Barcelona-Clinic Liver Cancer staging)

4 levels of staging
- A. Early stage(Child A, single lesion <5cm or 3 lesions max
3cm)
- B. Intermediate stage (Child B and/or large/ multifocal HCC)
- C. Advanced stage (Child C or vascular invasion or
Performance status>2)
- D. Terminal stage

BCLC (Barcelona-Clinic Liver Cancer staging)

Initial Management
Patients presenting acutely with
decompensated liver faillure require
specialist hepatological management.
Management principles include
attention to nutrition, careful fluid
balance and treatment of portal
hypertension

Treatment Strategies for HCC

Surgical resection
Liver transplantation
Radiofrequency ablation
Percutaneous ethanol/acetic acid injection
Transarterial embolisation/Transartrial
chemoembolisation (TACE).
Microwave/ cryoablation
Transarterial radiotherapy
Adjuvant systemic chemotherapy
etc

Surgical Resection (Tumor Removal)

If patients can withstand surgery and have enough liver
reserve (up to 5 in diameter with minimal blood
invasion)
The method choice and the extent of the resection
depend on the residual function of the remaining liver
Can remove up to 70% of a cancerous liver ( if no or
mild fibrosis)
Liver can regenerate in about 2~6 weeks following
surgery

Pre

Left Lobe
Volume = 608 cm3

% TLV = 33%

PV Embolization

Post

Left Lobe
Volume = 912 cm3

% TLV = 51%

Treatment of hepatocellular injury (AST)

with PEG interferon in the interval (10 weeks)

Surgical Resection (Tumor Removal)

Left hemihepatectomy : segments , and
Extended left hemihepatectomy: segments ,, , and

Right hemihepatectomy : segments,, and

Extended right hemihepatectomy : segments ,, ,
and
Left lobectomy : segments and
Right lobectomy : segments ~

FIGURE . Hepatic
resections. The type of
liver resection performed
depends on the type and
extent of the pathology.
(Adapted with permission from
Schwartz SI, ed. Principles of
Surgery. 6th ed. New York:
McGraw-Hill, Inc., Health
Professions
Division, 1994.)

Hepatocellular Carcinoma
Treatment Paradigm
HCC
Surgically resectable ?
No

Yes

Locoregional therapy ?
Yes
No

Resection

Arterial chemo embolisation

Radiofrequency ablation
Alcohol injection

Systemic therapy

Internal radiationetc

Liver Transplantation
Excellent cure for most patients, but limited organ supply
makes this option unattainable
Benefit for small, unresectable HCC and cirrhosis
Indications
: the patient is not a liver resection candidate
: the tumor(s) is smaller than or equal to 5 in diameter
: there is no macrovascular invlovement
: there is no identifiable extrahepatic spread of tumor to
surrounding LN, abdominal organs, or bone

Liver Transplantation
UNOS( the United Network for Organ Sharing)
* Eligibility criteria : a single hepatoma <5 or
: tumor nodules 3, each nodule 3
* While waiting for transplantation, chest, abdomen and
pelvis CT and bone scans every 6 months
4yr overall survival rate : 85%
The recurrence-free survival rate : 92%