Screening of patients with cirrhosis at risk of HCC: it must undertake an annual inspection of AFP and ultrasonography: who is at risk of developing HCC? We can interfere with cirrhosis? Among the causes of developing HCC in subjects with cirrhosis is infection with HBV, which replicates by reverse transcription and also integrates and produces a protein probably transattivante: the patient with cirrhosis with HBV should be closely followed. From our study emerges regarding screening on patients with cirrhosis:

18% had an infection with HBV + (+ HBV - HCV);

62% have HCV infection;

10% have a history of alcoholism;

3% for other causes;

7% are cryptogenic forms;

Cryptic HBV INFECTION AS CAUSE OF HCC

In our study: HCV and HBV serological profiles:

on 200 subjects positive for HCV ---> 100 markers had the anti Hbc Ab positive and 100 anti HBC -

on 50 subjects tested negative for HCV ---> 7 had the markers anti Hbc Ab positive, 43 anti-HBcAb negative;

As concerned HBV DNA

HBV + 66/200 to 46/100 where the markers were positive for anti Hbc

20/100 which had no positive markers for anti Hbc

So cryptic HBV infection can be the basis of an HCC, such as turning off the infection? IFN should be used? Studies it seems that in cirrhosis there is less incidence of HCC is established whether IFN. So if there is lower incidence in cirrhosis for HCC with IFN when this can be considered useful??

In a study dated July 1999:

1) The interferon reduces the risk of fewer than 2 times if the patient with CHILD A cirrhosis;

2) Interferon reduces by 3 times if the patient is HCV +;

3) Interferon decreases 6-fold risk if a person is HCV positive WITHOUT esposicione to HBV, and HBV positivity without risk is reduced by 6 TIMES!

Patients with infgezione cryptic virus B have more risk and respond to IFN evil, then promotes HBV cirrhosis and reduces the responders to IFN therapy.

DIAGNOSIS OF HCC

You have to assess patients at risk and no, that's different approach to the patient at risk from what is not, in any case a successful therapy in the treatment of HCC depends on good early diagnosis. What we get from a studio??

1) Identify the lesion

2) STRUCTURAL ANALYSIS OF INJURIES

3) STAGING

The techniques range from ECO * as a method of mass associated with research screenig Alpha Feto Protein, which is now extended by analyzing vascular MRI and CT for staging and vascular analysis, more must be reminded of the contrast-enhanced intraoperative ECO.

ultrasound study of 'HCC.

The ultrasound method is considered Level I and ECO sensitivity is reduced in cirrhosis where there are regenerative nodules that do not allow the recognition of initial lesions and therefore they get the reliability of 50%, the same is true for lesions less than 2 cm and there are important factors that go by the constitution of the patient, the presence of the nodule must be able to distinguish the context of the parenchyma and therefore to take into account the experience of the operator. In patients with cirrhosis, the sensitivity was 50%;

Ultrasound features of HCC:

If this is the appearance of small lesions may be hypo-or hyperechoic, hyperechoic HCC is not always distinguishable from angioma; E 'can, however, strengthen the technical and diagnostic skills using additional auxiliary methods: color Doppler and Power Doppler.

Power-over color Doppler investigation of higher sensitivity for small vessels and deep, but worse in the uncooperative patient who moves and / or lesions near the heart in patients with power Doppler U.S. can exclude neoplastic thrombosis of the door and / or the vase, so you can have a major study of the hypervascular lesion, you can have a studio and a spiral computerized three-dimensional reconstruction. It shows portal vein thrombosis and vascular pedicle of the lesion: eg. a hyperechoic lesion can be further investigated to assess the vascular pedicle, if more, there is thrombosis of the door then we can get a diagnosis. Is useful to employ even the MDC, Levovist, even in this technique ECO * that allows us to evaluate the vascular structure more accurately and thus to confirm the suspicion of HCC, the echo signal after Levovist * and the lesion is more intense and sharper assessing the lesion portal; in adenomatous hyperplastic nodules and no vascular signal in these cases is used successfully for Levovist DD with HCC.


ETC VOLUMETRIC OR SPIDER CT is the best technique for the study of tumor staging, even in uncooperative patients, spiral CT is scattered and it is easy even in uncooperative patients, because the exams are fast. The tumor is characterized by arterial hypervascularity and obviously to be identified, therefore, in the arterial phase, the technique is biphasic: arterial and portal. You use the artifice of the bolus test, ie it scans the aorta with a peak after 16'': so an interval program studying the circle: then we study first the aorta appear to be metal, because there is ejection, and expects the portal phase of the circle in which the blood passes into the liver parenchyma and soak the liver: HCC is identified obviously in the arterial phase, but sometimes also in the scanning vacuum if its size is larger: the contrast medium then disappears in the portal phase. In the portal phase, however, can highlight the tumor capsule. APPEARANCE: If the nodule is larger than 3 cm, can sometimes provide a central necrosis and hemorrhage with central cystic appearance in the arterial phase and portal. Other images on CT are represented by multiple foci of HCC and large HCC foci and / or sometimes small parenchymal lesions that accompany nodulini as difficult to assess in the context of parenchimna without these devices. Infiltrating HCC forms always affect the right lobe.

SENSITIVITY 'technology: for lesions <1 cm successful in 34%, 65% 1-2 cm,> 2 cm in 79%.

STAGING: multifocal invasion Web portal vessels, in 44% there can be no invasion of the portal vessels and this is indicative of poor radical therapy, in the arterial phase and portal phase we have the opportunity to study the presence of tumor thrombosis of portal vessels in these cases because the lesion appears hypodense poorly vascularized.

NMR

Newcomer nela diagnostics;

INDICATIONS:

1) Tissue characterization,

2) Vascular

3) Staging

4) identification (ie no injuries).

The innovations that were introduced in the technique allow us to better evaluate the liver parenchyma, although the patient is not cooperating, and the FAST IMMAGING can capture volume of whole liver, namely dynamic MRI to assess the arterial phase and portal; Dynamic imaging: hypervascularised HCC in the arterial phase and in the cirrhotic nodule is not to the stage where you can have the image of the bolus arterial injury, seen much better for gradient contrast. The characterization of vascular tumor is visible in the following percentages.

SENSITIVITY 'OF TECHNOLOGY. ------>> Size of <1 cm 55% 70% 1-2 cm,> 2 cm 80% of cases

Tissue characterization, namely chemical and structural tissue is a multiparameter technique in T1-weighted images, T2, DP and flow. SAT FAT technique consists of removing the contribution of fat and get a better contrast.


... T1-weighted images: T1 HCC will ipeintenso, because there is greater signal, the same if there is fat or even agents paramegnetici eg. Cu then the image will be hyperintense; lesion in phase and out STEP: You can get a study of the pseudocapsule: marginal and hypertensive: that is the "tissue characterization" sometimes as HCC lesions associated with hypertensive small hyperintense lesions. In the subject with as hemosiderin hemosiderin is paramagnetic T2 image is off, that is black, because black is zero: T2 then the liver and the lesion is black is black;



It 'can use the M.D.C. said "S.P.I.O." Super pramagnetic or iron oxide in the reticuloendothelial system. In this case, the nodules become blacks and no signal, the same applies to portal vein thrombosis after SPIO: thrombosis stands.

HCC Staging: Staging is important in determining whether the lesion affected the portal vein because in this case the prognosis is worse if the branch is concerned it will cut because there is no flow, while the lesion appears in the arterial phase and you can also study of arterio-venous shunt.

In the patient at risk can dignosi differential angioma, adenoma, focal nodular hyperplasia, metastases. MRI is a technique of the patient at risk and gives something more than the spiral CT. Finally there is to say that the study of tissue characterization capsule is found to be crucial for differential diagnosis with focal nodular hyperplasia because the capsule is present only in HCC.

TREATMENT OF 'HCC: 1) locoregional 2) to surgical) and segmental subsegmentaria

A large proportion of these patients have contraindications to the intervention of excision because they have a captive liver function: Child Class A, B, C, or because the cancer is at an advanced stage for which only palliative treatment is indicated.

Technique of destruction of the nodules after PEI, percutaneous or Fortification. prof. CASARIBAS

The screening program increased the No. of subjects who had HCC nodules and therefore were subjected to PEI.

A complete response to treatment will be if:

1) Action mechanism: direct tissue necrosis and ischemia by dehydration and denaturation of proteins;

2) ischemia of the tumor tissue with endothelial damage and thrombosis immediately, because if the MRI is a nodule with hyperintense pseudocapsule on T2, then we have a good answer, if there is fibrosis: no response;

Good response for HCC less than 3 cm, accessible to direct puncture and if the subject is class A or Child B;

Contraindications to treatment: ascites, bleeding <35% and platelets <40,000; for the presence of peripheral masses and metastases and whether the tumor is not encapsulated. HOW TO EVALUATE?

To see if we can intervene with an IEP hepatic arteriography, a CT arteriography, CT or lipiodol: at this stage whether there is a mass attempt a single embolization can be done even in surgery, anesthesia and injected with ethanol; sometimes under the direct echo.

SIDE EFFECTS: Pain, fever, leukocytosis, increase in transaminases intratumoral gas. You can make lidocaine for pain in the tumor mass.

COMPLICATIONS: emoperitone, portal vein thrombosis, tumor dissemination, hepatic abscess, pleurisy.

MORTALITY ': 1.7 to 4.6% at 30 days is <1%.

MRI is a technique for assessing the etanolizzazione and necrosis of the mass, together with spiral CT and arteriography was abandoned.

RESULTS: The study still is open and uncontrolled, success depends on the number of nodules, not all cancers have the same evolutionary, survival depends on the functional liver tissue and tumor size. At 3 years survival is 55-75% better if the patient is treated, which of course falls to 5.5%. For masses less than 5 cm in Class A at 5 years:

THERAPEUTIC SUCCESS FOR A 5 YEAR MASSES <5 cm class

In tumor resection 49% survival, 48% PEI, and embolization 44% 70% transplantation.

PRESENCE OF MULTIPLE CANCER IN SEPARATE FROM PRIMITIVE + METASTASES

If the presence of tumor recurrence or metastasis is separate from the original five-year survival is reduced: after PEI only 5% of survivors; metastases 17-46%, 50-50% new tumor

IN CONCLUSION: effective technique is easy, with few complications, but there are no control studies, selection of patients according to pathological features characterizing different results.



CHEMOEMBOLIZZAZIONE (TACE) is the symbol of blood chemoembolizzazione: indication and HCC in patients with cirrhosis.

RATIONALE: HCC is arterial vascularization, while the parenchyma is portal: therefore lead to the occlusion of tumor necrosis factor-saving liver, but what if the nodule size> 5 cm, each 3-5 cm in case of multiple nodules or as palliative treatment prechirugico.

However: there is no indication of whether the lesion is hypovascular, if the subject is in Child class C, if there are arteriovenous shunts, portal vein thrombosis that if there is an inadequate portal flow, if the residual volume liver function is> 40%. If you run a plurifocal HCC + lipiodol chemotherapy that is deposited on the wound and remains there for long: this is indicated for the treatment prechirugico, this palliative therapy to reduce the rate of growth (but do not go more than once a week this treatment).

MECC. Action: inject lipiodol chemotherapy ultrafluido + + gel foam. The lipiodol has the advantage of fixed and persists because the lesion is localized in the intra-and extracellular: ischemia and then determines the circle conveys the anticancer drugs on the tumor and results in an ischemic take effect. The chemotherapy is thus reduced by 50% with fewer systemic effects, with lower dose, then inject the gel foam or gelatin sponge to give peripheral ischemia, but only if there is a good portal flow and make the chemotherapy work better and the LUF.

When you search for the diagnostic evaluation for celiac vessels, making a wastewater portography, then studying any proper hepatic artery shunt. This raises the catheter downstream to prevent necrosis. We appreciate the nodules during parenchimografica; you start chemotherapy LUF + + + saline contrast medium: no more than 20 ml of lipiodol and do therapy or selective segmental subsegmentaria, follow the flow under fluoroscopy and then make the particles jelly. Or superselective segmental therapy: 2 cc of lipiodol hepatic lipiodol each branch x Tc after the first week. Control angiography to evaluate the results. Direct examination: LUF in the lesion, control: exclusion of the lesion.

Catheterization in superselective embolization proceed direct and control the mass after TACE.

EC * fever, pain, increased transaminase, decreased liver function, leukocytosis, insuff. renal failure, pancreatitis, all this may prevent the execution of the method OK.

THE LUF can be distributed on the mass

90% - 100% so thick or fuzzy, speckled, spot;

MRI is important for evaluation of hyperdense nodules that may mask the active outbreaks so we need contrast-enhanced MRI because there may be negative images lipiodol.

RESULTS: survival and better living

1 year: 60-80%

2 years 40-50%

The TACE is an effective palliative technique in non-operable and sometimes decisive in patients with single lesion from HCC.

Cryotherapy HCC

This is a technique that provides cold ablation technique for treatment of metastases. Computer control with liquid nitrogen, the probe is implanted in the lesion after laparotomy to create the so-called "ICE BALL". * PRO: the ablation is complete until the nodules of 5 cm and is extremely

homogeneous elements without active cancer, the ice ball, also stimulates the lymphocytes with better biological effect of PEI; hand * is required laparotomy that can be dangerous in cirrhosis, impossible nell'ascitico

after intervention may have worsening cold ablation is not radical where the nodule is located near a large vessel (exclusion criterion), the probe, probity and large, the phenomenon of cracking bleeding, and care in removal because the patient can bleed you must make debridement and suturing. COSTS: important, so now is the best machine you can use for RF lesions up to 6-7 cm.

A RADIO FREQUENCY ABLATION.

All these techniques, locoregional, are used when the individual can not be treated surgically because the subject is resective therapy reduces cirrhosis and liver function, then because there are technical difficulties for the Surgeon, and finally in a good percentage of cases multicentric disease: studies and even more accurate species of subjects undergoing angiography, there is a substaging: because the lesion is multicentrica.L 'HCC over 60 years and these patients may have diabetes, heart disease. In what is there to say that the resection leaves the underlying cirrhosis and there is a recurrence 5 years. The therapy is impractical to transplant organ shortage.

For these reasons, alternative treatments are indicated:

PEI-percutaneous ethanol or Iniection

Percutaneous-laserthermia

Percutaneous RF-interstistial Hipertermia

-Percutaneous Microwave Coagulation Therapy

Fiber lasers, however, are easily broken in the probe, then we get the use of RF to reduce the processing time and costs and this is the RF Interstitial Thermal Ablation or RITA.

The heat depends on the friction and ionic temperaura Killer is> 44 ° C; parameters: size of the surface can lead to temperature, exposure time, heat dissipation from the tissue impedance that depends on the hydration of the tissue, if is more hydrated better results, impedenz increases with decreasing water metastases do not have water, and then you have a bad outcome, then the pots are the heat. The area of coagulation necrosis termolesione is evolving towards anecrosi coagulation. The temperature increase is related to the increase in impedance and the increased hydration.

The RF needle .. 2 "gives 1.5 cm lesion. RITA: the alpha will be assessed fetoiproteinemia, U.S. CT, angiography studies as folloup, with masses of 1-2 cm tip of 15-18 G 1-6 sessions / week in 1-2 weeks.

In our study 39 subjects with HCC were divided into No. 20 in Class A Child, BN ° 17, 1 NC, and the size of the mass ranged between 1.8 to 3 cm. The first was alfaFetoProteinemia of 20 ng / ml and then became normal.

FOLLOW UP: We have performed before and after angio, CT scan showed an area devascularization.

However, after 22.6 months of follow-up we had 41% relapse. Recurrence and survival: a number less than 20% of subjects presented local recurrence, as well as new lesions for relapses, 5-year survival of 30%, however, our patients had an average of 66 years;

The Americans have produced needle electrodes that are out to 4 points with electronic spectrum and in eight minutes you get an area of 3.2 cm lesion, necrosis may occur for lesions less than 3 cm but you can stop the 'artery, the portal and hepatic veins draining to get a better result.

RESULTS: 1.5 to 2 sessions to achieve the result, treatment is uncomplicated, well tolerated, increase in GOT and GPT which fall in two weeks. Local recurrence and multicentric in advanced cancer, with RITA and TAE, the technique uses the stoppaggio vessel, artery corresponding to the lesion and the door, with Cater balloon.

And 'possible to vary the technique RITA + Lipiodol, technique of hepatic stop after termolesione to improve the result and not disperse heat.

RATIONALE:

We have a range of Child A where the surgery is definitely the best therapeutic technique, the use of other methods, the RF and PEI is placed in the patient which can not be done. We have a survival with surgery in six years! The chemoembolizzazione not have a therapeutic role too, the

6

supplementary vessels of phrenic and inferior mesenteric we create problems in intervening with the RF; more so we know the pot and use a great wisdom to avoid hepatic failure and ascites which will achieve functional discomfort. Portal vein thrombosis is not the only indication for therapy. The paintings are undoubtedly the best results in the Child A.

The stop is required because of hepatic if we stop increasing the impedance back to 30 to 40 and improves outcome.

Surgical treatment:

-Segmental resection

, Enlarged liver resections

Transplant-

Segmental liver resections may be, however, this treatment is simplistic but becomes necessary if the liver is unable to support an expanded treatment and there should be limited to segmentectomy or sub segmentectomy: The liver is divided into 8 segments as we provided with vascular pedicle such action may involve precisely:

- That is, the smaller segmental resections and anatomic subsegmentarie

- Non-anatomical resections or wedge.

The subjects in our series comprises 75.5% of Child class A, B = 23% C 1.5%, we know that 90% of HCC on cirrhosis implants and 10% no cirrhosis; HBV can be positive.

* DIRECTIONS FOR: single nodule, limited to one segment (optimum), <5 cm AGAINST: Horse of hepatic nodules, subject in Child A or B 7, indiocianina> 30.

TECHNOLOGY: hepatic vascular occlusion after clamping segment, emiepatico or liver. Results: operative mortality of 3%; COMPLICATIONS: high, ascites, renal impairment, right pleural effusion, the dosage of ALT correlates with mortality if it is> 2 times normal, then the mortality is between 25-28% for the HCC 5-year survival is 45% if there is cirrhosis, recurrence in 45% greater if the technique is Wedge, versus anatomical resection. The recurrence can be reprocessed with re-resection or PEI.

CONCLUSIONS: Radical but relapse rates should not be underestimated, but the results will improve with immunotherapy and gene therapy

Class A is the maximum indication of segment 8 lesions between the middle hepatic and right there are alternative treatments: results of recidivism for minor anatomic and wedge between 26 and 41%, 19% for 2 segments, 's Anatomical> 13%.

The segmentectomy of segment II and III is used for 50% of cases, others are less frequent. The s. involves the removal of the tumor tissue +, binds to the presence of segmental portal vein thrombi cancer, resection is the origin of the hepatic pedicle; sometimes requires multiple tumor resection of multiple segments. The Wedge has recurrences> of 47-76% to the anatomical. Is a vital intra-ECO; identifies the segment and is involved with and hilarious approach transparenchimale injecting dye in the pedicle, hilarious approach we proceed by ILO; approach transparenchimale denucleated segment is obtained by parenchyma. The surgery is done with a margin of 1.5 cm more Why should broaden and not to enucleation alone. The subsegmentectomia should be guided contrast-enhanced intraoperative and ECO: The patients were staged with LUF; relapse is a dissemination portal or ignored satellite nodule. The TACE is not used before surgery, today is avoided because there is to lose valuable time, so the only TACE as a parking lot.

"We must stress I think the diagnostic act, because I do not think al'unicità injuries." The fork on the caval segment, the range of hepatic if <3 cm can do RF but I close the jars, if the tumor capsule then it makes sense to exploit the effect of the RF and oven if I close the ' artery flow, however, I must also shut the door. I put a thermistor and assess. The line will be soon followed by the therapeutic technique of immunostimulation with interleukin II

Major liver resection

The more extensive resection should always be avoided: About 360 patients with HCC we have only 100 major resections, the subjects had TNM stages between 1 and 2, the 5-year survival was 40%, the straight line is where the transplanted subject is, however, that transplantation is the ideal, with 80% survival. In cirrhosis there is a risk that the tumor embolisation the door, the five-year survival is 0.6% for metastases, HCC without cirrhosis at 4.7, 1.9% for HCC with cirrhosis.
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