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Staging Strategy and Treatment for Patients With HCC Liver transplant RFA/PEI Curative treatments TACE Single Increased Associated diseases Normal NoYes.

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Presentation on theme: "Staging Strategy and Treatment for Patients With HCC Liver transplant RFA/PEI Curative treatments TACE Single Increased Associated diseases Normal NoYes."— Presentation transcript:

1 Staging Strategy and Treatment for Patients With HCC Liver transplant RFA/PEI Curative treatments TACE Single Increased Associated diseases Normal NoYes Terminal stage PST 0-2, Child-Pugh A-B Multinodular, PST 0 Sorafenib Portal pressure/bilirubin 3 nodules ≤ 3 cm N1, M1, PST 1-2≤ 3 cm, PST 0 Intermediate stage PST > 2, Child-Pugh C Very early stage Single < 2 cm Early stage Single or 3 nodules Advanced stage Portal invasion, PST 0, Child-Pugh A Resection Symptomatic HCC Palliative treatments Forner A, Reig ME, de Lope CR, Bruix J. Current strategy for staging and treatment: the BCLC update and future prospects.Semin Liver Dis. 2010;30(1):61-74

2 Liver transplantation RFA/PEI Curative treatments (30%); 5-yr survival: 40%-70% TACE Single Increased Associated diseases Normal NoYes Sorafenib Portal pressure/bilirubin 3 nodules ≤ 3 cm Resection Symptomatic (20%); survival < 3 mos RCTs (50%); 3-yr survival: 10%-40% Terminal stage (D) Okuda 1-2, PS 0-2, Child-Pugh A-B Multinodular, PS 0 N1, M1, PS 1-2< 3 cm, PS 0 Intermediate stage (B) Okuda 3, PS > 2, Child-Pugh C Very early stage (0) Single < 2 cm Carcinoma in situ Early stage (A) Single or 3 nodules Advanced stage (C) Portal invasion, PS 0, Child-Pugh A HCC BCLC Staging and Treatment Strategy Llovet JM, et al. Design and endpoints of clinical trials in hepatocellular carcinoma. Journal of the National Cancer Institute. 2008;100(10):698-711, by permission of Oxford University Press.

3 BCLC Staging System Terminal stage (D) Okuda 1-2, PS 0-2, Child-Pugh A-B Multinodular, PS 0 N1, M1, PS 1-2< 3 cm, PS 0 Intermediate stage (B) Okuda 3, PS > 2, Child-Pugh C Very early stage (0) Single < 2 cm Carcinoma in situ Early stage (A) Single or 3 nodules Advanced stage (C) Portal invasion, PS 0, Child-Pugh A HCC Llovet JM, et al. Design and endpoints of clinical trials in hepatocellular carcinoma. Journal of the National Cancer Institute. 2008;100(10):698-711, by permission of Oxford University Press. Stage 0Stage A-CStage D

4 Liver Transplantation for HCC: Milan Criteria (Stage 1 and 2) 5-yr survival with transplantation: ~ 70% 5-yr recurrent rates: < 15% + Absence of macroscopic vascular invasion, absence of extrahepatic spread Single tumor, not > 5 cm Up to 3 tumors, none > 3 cm Mazzaferro V, et al. N Engl J Med. 1996;334:693-699. Llovet JM. J Gastroenterol Hepatol. 2002;17(suppl 3):S428-S433.

5 Candidates for RFA/PEI Includes individuals who are not candidates for surgery Radiofrequency ablation generally preferred over percutaneous ethanol injection – Necrotic effect more predictable across tumor sizes – Meta-analyses suggest survival benefit with radiofrequency ablation vs percutaneous ethanol injection Bruix J, et al. AASLD HCC guidelines. July 2010.

6 Liver transplantation RFA/PEI Curative treatments (30%); 5-yr survival: 40%-70% TACE Single Increased Associated diseases Normal NoYes Sorafenib Portal pressure/bilirubin 3 nodules ≤ 3 cm Resection Symptomatic (20%); survival < 3 mos RCTs (50%); 3-yr survival: 10%-40% Terminal stage (D) Okuda 1-2, PS 0-2, Child-Pugh A-B Multinodular, PS 0 N1, M1, PS 1-2< 3 cm, PS 0 Intermediate stage (B) Okuda 3, PS > 2, Child-Pugh C Very early stage (0) Single < 2 cm Carcinoma in situ Early stage (A) Single or 3 nodules Advanced stage (C) Portal invasion, PS 0, Child-Pugh A HCC Unresectable HCC BCLC Staging and Treatment Strategy Llovet JM, et al. Design and endpoints of clinical trials in hepatocellular carcinoma. Journal of the National Cancer Institute. 2008;100(10):698-711, by permission of Oxford University Press.

7 Llovet JM, et al. Hepatology. 2003;37:429-442. Arterial Embolization for HCC Meta-analysis of 6 RCTs (2-Yr Survival) Random Effects Model, OR (95% CI) Author, Journal YrPatients, n Lin, Gastroenterology 198863 GETCH, NEJM 199596 Bruix, Hepatology 199880 Pelletier, J Hepatol 199873 Lo, Hepatology 200279 Llovet, Lancet 2002112 Overall503 Median survival: ~ 20 mos 0.01 0.10.51210100 Z = -2.3 P =.017 Favors TreatmentFavors Control

8 Contraindications to TACE Extrahepatic tumor spread Lack of portal blood flow – Portal vein thrombosis, portosystemic anastomoses or hepatofugal flow Advanced liver disease (Child-Pugh Class B or C) Clinical symptoms of end-stage cancer Bruix J, et al. AASLD HCC guidelines. July 2010.

9 Liver transplantation RFA/PEI Curative treatments (30%); 5-yr survival: 40%-70% TACE Single Increased Associated diseases Normal NoYes Sorafenib Portal pressure/bilirubin 3 nodules ≤ 3 cm Resection Symptomatic (20%); survival < 3 mos RCTs (50%); 3-yr survival: 10%-40% Terminal stage (D) Okuda 1-2, PS 0-2, Child-Pugh A-B Multinodular, PS 0 N1, M1, PS 1-2 < 3 cm, PS 0 Intermediate stage (B) Okuda 3, PS > 2, Child-Pugh C Very early stage (0) Single < 2 cm Carcinoma in situ Early stage (A) Single or 3 nodules Advanced stage (C) Portal invasion, PS 0, Child-Pugh A HCC BCLC Staging and Treatment Strategy Llovet JM, et al. Design and endpoints of clinical trials in hepatocellular carcinoma. Journal of the National Cancer Institute. 2008;100(10):698-711, by permission of Oxford University Press.


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