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Carcinoma)hepatocelular: Estadio inicial - · PDF file >52years Portal*pressure*Bilirubin Potential*candidate*for*liver* transplantation* No Yes Normal Effectivetreatmentswith impact

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  • Carcinoma  hepatocelular:  Estadio inicial

    Alejandro  Forner

    BCLC  Group.  Liver  Unit.   Hospital  Clínic.  CIBERedh.  University  of  Barcelona

    VI  CURSO  DE  RESIDENTES  AEEH Barcelona,  10-­‐11  Noviembre  2017

  • Question  #1

    Respecto  al  hepatocarcinomaen  estadio  inicial,  señale  usted  la   respuesta  incorrecta:

    1.-­‐ Es  posible  su  diagnóstico  mediante  técnicas  de  imagen  sin   necesidad  de  realizar  una  biopsia

    2.-­‐ Con  los  tratamientos  disponibles  es  posible  obtener  una   supervivencia  a  5  años  superior  al  50%

    3.-­‐ Es  aceptable  una  mortalidad  intraoperatoriadel  5%  en  aquellos   pacientes  afectos  de  CHC  inicial  tratados  mediante  resección   quirúrgica

    4.-­‐ La  función  hepática  es  un  parámetro  fundamental  para  elegir  la   mejor  opción  terapéutica.

  • Early  stage  (A) Single  or  3  nodules  <  3cm

    Preserved   liver   function*,  PS  0

    Portal  pressure  Bilirubin

    Solitary 3  nodules  ≤3cm

    Associated   diseasesIncreased

    No Yes

    Potential  candidate  for  liver   transplantation  

    No Yes

    Normal

    Effective treatmentswith impact on survival

    Intermediate    stage  (B) Multinodular

    Preserved   liver   function*,  PS  0  

    Advanced    stage  (C) Portal  invasion  

    Extrahepatic spread Preserved   liver   function*,  PS  1-­‐2

    HCC

    Terminal  stage  (D) End-­‐stage  liver   function**

    PS  3-­‐4

    Very  early  stage  (0)   Single<  2cm

    Preserved   liver   function*,  PS  0

    Tr ea tm

    en t

    Pr og no si s

    *This  term  includes  a  heterogeneous  group  of   patients  with  different  degree  of  liver  function  reserve    that  has  to  be  carefully  evaluated.  For  most  treatment  options,  compensated  liver   disease    (Child-­‐Pugh   A  without  ascites)  is  requested  to  obtain  optimal  outcomes.    The  sole  option  that  may  be  applied  irrespective  of  liver  function  is  liver  transplant.  Most  of  them  are   compensated   and  fitting  into  the  Chilld-­‐Pugh  stage  A.**Patients  with  end  stage  cirrhosis  due  to  heavily  impaired  liver  function  (Child-­‐Pugh  C  or  earlier  stages  with  predictors  of  poor   prognosis,  high  MELD  score)   should  be  considered   for   liver  transplantation.  In  them  HCC  may  become  a  contraindication  if  exceeding  the  enlistment  criteria.    ***Currently sorafenib followed by regorafenib has  been shown to  be  effective.  lenvatinib has  been shown to  be  non-­‐inferior  to  sorafenib,   but no  effective second line  option after lenvatinib has  been explored.

    Chemoembolization Systemictherapy***TransplantResectionAblation Ablation BSC

    >5  years >2.5  years >1  year 3  months

    Su rv iv al

    BCLC  Staging  and  Treatment  Strategy,  2017

    Forner  A,  Reig ME,  Bruix J.  Lancet.  2017.  Accepted.

  • >5  years

    Early  stage  (A) Single  or  3  nodules  <  3cm

    Preserved   liver   function*,  PS  0

    Portal  pressure  Bilirubin

    Solitary 3  nodules  ≤3cm

    Associated   diseasesIncreased

    No Yes

    Potential  candidate  for  liver   transplantation  

    No Yes

    Normal

    Effective treatmentswith impact on survival

    HCC

    Very  early  stage  (0)   Single<  2cm

    Preserved   liver   function*,  PS  0

    Tr ea tm

    en t

    Pr og no si s

    *This  term  includes  a  heterogeneous  group  of   patients  with  different  degree  of  liver  function  reserve    that  has  to  be  carefully  evaluated.  For  most  treatment  options,  compensated  liver   disease    (Child-­‐Pugh   A  without  ascites)  is  requested  to  obtain  optimal  outcomes.    The  sole  option  that  may  be  applied  irrespective  of  liver  function  is  liver  transplant.  Most  of  them  are   compensated   and  fitting  into  the  Chilld-­‐Pugh  stage  A.**Patients  with  end  stage  cirrhosis  due  to  heavily  impaired  liver  function  (Child-­‐Pugh  C  or  earlier  stages  with  predictors  of  poor   prognosis,  high  MELD  score)   should  be  considered   for   liver  transplantation.  In  them  HCC  may  become  a  contraindication  if  exceeding  the  enlistment  criteria.    ***Currently sorafenib followed by regorafenib has  been shown to  be  effective.  lenvatinib has  been shown to  be  non-­‐inferior  to  sorafenib,   but no  effective second line  option after lenvatinib has  been explored.

    TransplantResectionAblation Ablation

    Su rv iv al

    Forner  A,  Reig ME,  Bruix J.  Lancet.  2017.  Accepted.

    Natural  history:  Unknown

    Survival:  12-­‐65%  at  3  years

    BCLC  Staging  and  Treatment  Strategy,  2017

  • EASL–EORTC  Clinical  Practice  Guidelines.   J  Hepatol.  2012:56(4);908-­‐43  

    3

    2

    1

    2  (weak) 1  (strong)

    Grade  of   recommendation

    Levels  of   evidence

    Sorafenib

    Chemoembolization

    RF

  • >5  years

    Portal  pressure  Bilirubin

    Potential  candidate  for  liver   transplantation  

    No Yes

    Normal

    Effective treatmentswith impact on survival

    HCC

    Very  early  stage  (0)   Single<  2cm

    Preserved   liver   function*,  PS  0

    Tr ea tm

    en t

    Pr og no si s

    *This  term  includes  a  heterogeneous  group  of   patients  with  different  degree  of  liver  function  reserve    that  has  to  be  carefully  evaluated.  For  most  treatment  options,  compensated  liver   disease    (Child-­‐Pugh   A  without  ascites)  is  requested  to  obtain  optimal  outcomes.    The  sole  option  that  may  be  applied  irrespective  of  liver  function  is  liver  transplant.  Most  of  them  are   compensated   and  fitting  into  the  Chilld-­‐Pugh  stage  A.**Patients  with  end  stage  cirrhosis  due  to  heavily  impaired  liver  function  (Child-­‐Pugh  C  or  earlier  stages  with  predictors  of  poor   prognosis,  high  MELD  score)   should  be  considered   for   liver  transplantation.  In  them  HCC  may  become  a  contraindication  if  exceeding  the  enlistment  criteria.    ***Currently sorafenib followed by regorafenib has  been shown to  be  effective.  lenvatinib has  been shown to  be  non-­‐inferior  to  sorafenib,   but no  effective second line  option after lenvatinib has  been explored.

    ResectionAblation

    Su rv iv al

    Forner  A,  Reig ME,  Bruix J.  Lancet.  2017.  Accepted.

    BCLC  Staging  and  Treatment  Strategy,  2017

  • Tumor  cell invasion into the portal  vein and  minute  intrahepatic metastases in   the vicinity of  the tumor  are  observed in   27%  and  10%  of  distinctly nodular   small HCCs,  respectively,  but not observed in  

    indistinctly nodular   small HCCs

    Prognostic  scoring  systems  for  HCC Very  early  HCC

    KojiroM,  Roskams T.  Semin Liver  Dis.  2005;25:133-­‐142. Hasegawa K  et  al.  J  Hepatol 2013;58:724-­‐729.

    Patients  CP-­‐A  (n=785)   5-­‐year  survival:  83.9%

    Si ng le  tu

    m or  <   2c m

    CP-­‐A  and  platelet  >150,000/mm3 (n=66)  

    5-­‐year  survival:  81%

    Roayaie S.  et  al.  Hepatology 2013:57(4):1426-­‐35.

  • Overall  Survival  Rate  (%) Study No.  of  patients 1  year 3  year 5  year

    Lencioni et  al.  2005 Child-­‐Pugh  A 144 100% 76% 51% Child-­‐Pugh  B 43 89% 46% 31%

    Tateishi et  al.  2005 Chil

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