Welcome back. Thanks for joining me on this discussion of liver cancer under the section
of general surgery. What’s primarily called primary hepatoma is actually hepatocellular carcinoma.
All factors that predispose to cirrhosis are risk factors for hepatomas or hepatocellular carcinoma.
As I mentioned, it’s a common misnomer but in fact, primary hepatomas of the liver are malignant
and should really be called hepatocellular carcinoma. Again, cirrhosis and hepatitis
particularly B and C are risk factors for hepatocellular carcinoma. Increasingly, NASH
or nonalcoholic steatohepatitis which is associated with obesity, type 2 diabetes, dyslipidemia,
hypertension are the metabolic syndrome. The incidence are the highest in Asia
largely because of active hepatitis infections. NASH, to remind you is again increasingly common
due to the obesity and metabolic syndromes particularly in the west. NASH stand for
nonalcoholic steatohepatitis associated with the metabolic syndrome. Physical findings of liver cancer
may include a palpable mass or a nonspecific right upper quadrant discomfort. The vast majority
of patients do not complain of any abdominal pain. In later stages, there may be cancer-related
weight loss and there may be jaundice when the biliary system is obstructed. In very late stages
of cirrhosis, you may find ascites or fluid. This is due to the poor portal venous system drainage.
These findings would be consistent with cirrhosis. Here is a picture of a patient getting ascites
drained from the abdomen. This is likely secondary to the hepatic cirrhosis. Also note, this patient
also appears to be jaundiced. Unfortunately, draining of the ascites is usually just symptomatic
treatment as it does not treat the cirrhosis. What are some other common findings?
We talked about weight loss, potentially early satiety, and anemia. On common laboratory values,
we may actually see a low sodium level. Hyponatremia is a poor prognostic indication for liver function.
Additionally, we may actually see a drop in the hematocrit. Other common tests that are obtained
is the alpha-fetoprotein as a tumor marker for liver cancer. Additionally, we always assess
the liver synthetic function mainly by its coagulation profile, PT, PTT, and INR. As you’re aware of,
they are vitamin K dependent factors that are synthesized in the liver. AST and ALT may be
variably elevated. Here’s a cross sectional imaging or CT scan of the abdomen and pelvis demonstrating
multiple liver lesions. You’ll notice the highlighted regions. There are approximately three lesions
in this liver. Now, remember from previous lectures, this may also represent metastatic disease.
So, the clinical context is very important. Should we do a biopsy? It’s controversial.
It’s not worthwhile for small lesions, less than 1 cm. As a reminder, CT scan images
may not even pick up lesions smaller than 1 cm. But it is probably worthwhile for larger tumors
to determine the next steps. Remember, liver biopsy, although often done percutaneously
either by an interventional radiologist or by a hepatologist under guidance, now usually ultrasound
does carry some risks. These risks include bleeding particularly if the patient is cirrhotic and already
has liver synthetic dysfunction. An important classification for the cirrhosis severity is called
Child Pugh classification. Each of the five categories are assigned a score of 1 to 3.
They include encephalopathy, ascites, bilirubin, albumin, and INR. The combining of these scores
gives you an idea of how much of postoperative or perioperative mortality the patient may experience.
Here’s the classification. You’ll commonly hear us discuss Child’s Pugh class A, B, or C.
Class A patients have a total of about 5-6 points. This is considered mild cirrhosis
and has a less than 5% chance of operative mortality. In Child’s B classification, these patients
have heightened risks. Their total points are approximately 7-9 with moderate to severe
disease of cirrhosis. These patients carry significant perioperative mortality of upwards of 25%.
The sickest of all cirrhotic patients are class C. These patients score approximately 10-15 points
that are severe cirrhotics and generally speaking not candidates for surgery as they have
prohibitive operative mortality. Recently, development of MELDs or Model for End Stage Liver Disease
has surpassed Child’s Pugh as a more accurate predictor of mortality. Although originally developed
for assigning cirrhosis staging for liver transplantation, multiple studies now have demonstrated
that MELD is actually quite accurate for predicting perioperative mortality. It’s a little bit different
than the Child’s Pugh classification, however. Take a look at this table. MELD includes creatinine,
bilirubin, INR, and the latest iteration is the incorporation of sodium. Recognize that unlike
the Child’s Pugh classification, these are objective findings, all laboratory results as opposed to
encephalopathy or ascites which are potentially subjective. I like to pose a question to you.
What constitutes resectable disease in liver cancer? I’ll give you a second to think about this.