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Liver Cancer

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Liver Diseases

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Abstract

Hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (iCCA) are the most frequent primary malignancies of the liver, with increasing incidence rates worldwide, especially among patients with chronic liver disease. The molecular pathogenesis of liver cancer is complex, although in recent years there has been considerable progress in understanding the mechanisms of hepatic and biliary carcinogenesis. Screening of patients at risk is of paramount importance to diagnose liver cancer at an early stage, when the available treatment strategies are most effective. Liver imaging is rapidly progressing, and the available dynamic imaging techniques usually permit a definite diagnosis without the need of liver biopsy. Pathological diagnosis however is still recommended for all atypical lesions either in cirrhotic or in noncirrhotic patients. Liver resection (LR) and liver transplantation (LT) are potentially curative for HCC and iCCA, but only a minority of patients with early tumour stages are surgical candidates. Minimally invasive percutaneous ablative treatments, including radiofrequency ablation (RFA), ethanol injection (PEI), and other recent techniques, are increasingly used, especially in case of smaller lesions, as an alternative to liver surgery in appropriately selected patients. A variety of locoregional therapies, including transarterial chemoembolization (TACE) and radioembolization (TARE), radiation therapy (RT), and systemic therapies are employed to treat unresectable or recurrent disease. The choice of the most appropriate treatment strategy in the single patient is based on the neoplastic burden and on the liver function, which needs to be accurately evaluated according to the underlying liver disease and to the performance status. Treatment of liver cancer is multidisciplinary and should involve hepatologists, hepato-biliary surgeons, radiologists, including interventional radiologists, and oncologists, to achieve the optimal outcome according to the tumour stage and liver functional reserve.

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Author information

Authors and Affiliations

  1. Unità Operativa di Chirurgia Generale, Dipartimento dell’Apparato Digerente, Azienda Ospedaliero-Universitaria di Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy

    Emilio De Raffele

Authors
  1. Emilio De Raffele
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Correspondence to Emilio De Raffele .

Editor information

Editors and Affiliations

  1. Faculty of Medicine, “Titu Maiorescu” University, Central Military Emergency University Hospital “Dr. Carol Davila”, Bucharest, Romania

    Florentina Radu-Ionita

  2. New Jersey Medical School, Rutgers University New Jersey Medical School, Newark, NJ, USA

    Nikolaos T. Pyrsopoulos

  3. Carol Davila University of Medicine and Pharmacy, Central Military Emergency University Hospital “Dr. Carol Davila”, Bucharest, Romania

    Mariana Jinga

  4. Faculty of Medicine, “Titu Maiorescu” University, Central Military Emergency University Hospital “Dr. Carol Davila”, Bucharest, Romania

    Ion C. Tintoiu

  5. Medical Radiation Sciences, Curtin University, Perth, WA, Australia

    Zhonghua Sun

  6. “Prof. C.C. Iliescu” Emergency Institute for Cardiovascular Diseases, Bucharest, Romania

    Ecaterina Bontas

Self Study

Self Study

1.1 Questions

  1. 1.

    Which groups of patients at risk of HCC should undergo surveillance?

    1. (a)

      Cirrhotic patients with:

      • HBV infection.

      • HCV infection.

      • NASH.

      • Primary biliary cirrhosis.

    2. (b)

      Noncirrhotic patients with:

      • Chronic HBV hepatitis, in Asian and African countries where HBV infection is endemic.

      • Chronic HCV hepatitis and bridging fibrosis.

      • NAFLD.

    3. (c)

      Patients treated for chronic viral hepatitis:

      • With sustained HBV-DNA suppression or HBeAg seroconversion in chronic hepatitis B.

      • With sustained viral response in chronic hepatitis C with advanced fibrosis or cirrhosis.

    4. (d)

      All these groups.

  2. 2.

    Which is the typical behaviour of intrahepatic cholangiocellular carcinoma at dynamic CT?

    1. (a)

      Arterial phase hyperenhancement (APHE) with washout in the portal venous or delayed phases.

    2. (b)

      Peripheral rim enhancement in the arterial phase, and progressive centripetal enhancement during the venous and delayed phases, commonly lasting several minutes.

    3. (c)

      Peripheral nodular or globular enhancement in the arterial phase, with a centripetal progression or “filling in” in the portal venous and delayed phases; the tumour opacifies after a delay of three or more minutes and remains isodense or hyperdense on delayed scans.

1.2 Answers

  1. 1.

    Which groups of patients at risk of HCC should undergo surveillance?

    1. (a)

      Cost-effectiveness studies suggest that an incidence of HCC of >1.5% per year would require implementing surveillance strategies of HCC in cirrhotic patients, irrespective of its aetiology; HBV and HCV infection, NASH and primary biliary cirrhosis are related to high risk of HCC occurrence.

    2. (b)

      HCC can occur even in the absence of cirrhosis in patients with chronic HBV hepatitis, in Asian and African countries where HBV infection is endemic; with chronic HCV hepatitis and bridging fibrosis; and with NAFLD.

    3. (c)

      Successful antiviral treatments determining sustained HBV-DNA suppression or HBeAg seroconversion in chronic hepatitis B, and sustained virological response in chronic hepatitis C, reduce, but do not eliminate the risk of developing HCC. As a consequence, treated patients with chronic hepatitis B who remain at risk of HCC occurrence because of baseline factors, and those with HCV-related advanced fibrosis or cirrhosis, should undergo surveillance even after achieving sustained viral response.

    4. (d)

      CORRECT. All these groups are at risk of developing HCC and should receive appropriate surveillance.

  2. 2.

    Which is the typical behaviour of intrahepatic cholangiocellular carcinoma at dynamic CT?

    1. (a)

      Hepatocellular carcinoma typically shows arterial phase hyperenhancement (APHE) with washout in the portal venous or delayed phases on CT and MRI using extracellular contrast agents, and APHE with washout in the portal venous phase on MRI using Gd-EOB-DTPA.

    2. (b)

      CORRECT. Intrahepatic cholangiocellular carcinoma typically appears as a hypodense hepatic mass with irregular margins in the precontrast phase on CT, with peripheral rim enhancement in the arterial phase, and progressive centripetal enhancement during the venous and delayed phases, over several minutes, related to the fibrotic tissue within the cancer.

    3. (c)

      Hepatic hemangioma typically appears as a well delineated hypodense lesion in the precontrast phase on CT, with peripheral nodular or globular enhancement in the arterial phase, with a centripetal progression or “filling in” in the portal venous and delayed phases; the tumour typically opacifies after a delay of three or more minutes and remain isodense or hyperdense on delayed scans; this pattern is observed in up to 94% of hemangiomas larger than 4 cm.

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De Raffele, E. (2020). Liver Cancer. In: Radu-Ionita, F., Pyrsopoulos, N., Jinga, M., Tintoiu, I., Sun, Z., Bontas, E. (eds) Liver Diseases. Springer, Cham. https://doi.org/10.1007/978-3-030-24432-3_31

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  • DOI: https://doi.org/10.1007/978-3-030-24432-3_31

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